GW1-2021-00526_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
Gary Thompson 14.WATER ZONES4.::-
Well Contractor Name FROM TO DESCRFMON
4418-A
e. 70
ft.
ft. ft.
NC Well Contractor Certification Number 15r OUTER CASING for multi-cased wells OR LINER ifa' licable 4+
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. In ( �Ir
Company Name �v
`,� '16 INNER CASING.OR':TUBING. eothermei dosed loo `°
2.Well Construction Permit#: ��'©�� �IJHn•t�7�IQ FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. In.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17:,SCREEN ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. fL in.
i Geothermal(Heating/Cooling Supply) wResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared)
18:.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. fL
Monitoring Recovery ft. ft.
Injection Well:
ft. it
Aquifer Recharge Groundwater Remediation
.19;:SAND/GRAVEL PACK(if a"'"licsble .
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attacbadditional'sheets if riecessa
Geothermal (Heating/Cooling Return) ,Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck typp,gmin size,etc.
Id
fL fL
4.Date Well(s)Completed: 1 1-10 4 1 Well ID#
5a.Well Location: 44k' K68
r
1 ma Line Rdme.S ft. fL
Facility/Owner Name ` Facility lD#(if applicable) ft. ft. U
C 2 ft
'riH. MG1,aLsnSll'.��Ei !JC _ � fL fL —
Physical Address,City,and Zip ft. fL c
21iREMARKS.
Cxrt�l�'n1�)
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ift�wee0 field,one llaa1t(nlong is sufficient) 22.Certification:
�llp6 �t of/.qb N NO L16t �U.lu W
6.Is(are)the well(s)dPermanent or [3Tempo;No
Signature of Cert' ell Contra r Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details'
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 2 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Cef ter,Raleigh,NC 27699-1617
11.Borehole diameter: (a (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n Wu p s above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: YEA N construction to the following:
(i.e.auger,rotary,cable,direct push etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of test: (� �-T,511@ 24c.For Water SUDDIy&Iniection Wells: In addition to sending the form to
the address(es) above, also submit j one copy of this form within 30 days of
13b.Disinfection type: uTH W/O Amount: 1(.cw— completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016