GW1-2021-00582_Well Construction - GW1_20211222

Prin Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Gary Thompson 14.WATER ZONES
Well Connector Name
FROM TO DESCRIPTION
4418-A 0 ft, 907 it- UP. fr
NC Well Contractor Certification Number ft' 408
ft M SC)
15.OUTER CASING for multi�ased wells OR LINER; a Hcabie
Aqua Drill, Inc. FROM TO DIAl17ETER THICKNESS MATERIAL
O ft. C1 it. in. ` [1�.e
Company Name :J 1'V
16:INNER CASING OR TUBING'tde6theraiii closedaoo
2.Well Construction Permit#: LRUP'l1fi3.Ou3 FROM I TO I DIAMETER I TRic—K—m—s--T MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. I in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural unicipal/Public R, It. in.
Geothermal(Heating/Cooling Supply) r3kesidential Water Supply(single) ft. ft. ,n
Industrial/Commercial DResidential Water Supply(shared)
i8:-GROUT
[Geothermal
on FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ter Supply Well: O ft. ft, it
ring Recovery ft. ft.
n Well:
ft. ft.
- r Recharge- Groundwater Remediation
19 SAND/GRAVEL=PACK if,a"licable `` .
r Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
r Test [3Stormwater Drainage ft. ft.
mental Technology Subsidence Control ft. ft
rmal(Closed Loop) Tracer 20 DRILLING LOG attach additional'sheets if necessary)
l eaten Conlin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,bards soiVrock a in si etc
ft. It.
4.Date Well(s)Completed:4 j- - Well ID# ft. 46 ft. Dpf ,
5a.Well Location: ft- ` ft t
ft It.
lIIS't7�•lfLfl ���tnS �nat`1i11�t� t
Facility/Owner Name Facility ID#(if applicable) ft. ft.
,2529 Soh ` U'ik, JX 004 ft. ft -
Physical Address,City,and Zip
l ft. ft
f1AP.�f�f1d�l�if1 21 REMARKS
County Parcel Identification No.(PEN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certification: t , �,,, v '"_: o � .:�•,,�v r,a i
6.Is(are)the wells) ' Permanent or Temporary Signature f nified 0 Contractor 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: 13Yes or 1]3/No with 15A NCAC 02C.0100 or 15.4 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 ofthis 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: 4oICJ 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells&I all depths if different(example-3Q20oo0��'ffa''nd 2@100) construction to the following:
10.Static water level below top of casing: MY (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (a (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t above,also submit one copy of thiskform within 30 days of completion of well
12.Well construction method: ke SOW
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) �_ Method of.test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
1' the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: NTH 7O h- .."Amount: 160-L completion of well construction to the county health department of the county
where constructed.
�� I
Form GW-1 North G iolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016