GW1-2022-00903_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER'ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A ft.
NC Well Contractor Certification Number ,`&OUTER CAS for multi-cased wells OR'LINER if a livable
Aqua Drill, Inc. FROM T DIAMETER THICKNESS MATERIAL,
ft. it in.
Company Name
16. R:C SING. RTUBING eothermaldosed400
2.Well Construction Permit#: Q4(")9"Q1o5-c)IS FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft 1n.
3.Well Use(check well use): A
Water Supply Well: 17..SCREEN
FROM TOI DIAMETER LO Im ESS MATERIAL
Agricultural13 unicipaUPublic ft, ft i
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial E2Residential Water Supply(shared)
18.GROUT.:' '"
Irrigation FROM TO MATERIAL PLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 13Recovery ft. ft
Injection Well: k ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attacti'Additlonal sheets if riecessa
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness,soil/reck type,grain size,etc
ft. ft s
4.Date Well(s)Completed: 1 - -� Well ID# ft. ft.
5aa.We�ll Lfolcation: ft. ft.
�
FaciliR//Owner Name Facility ID#(if applicable) B' ft.
` ft. ft.
i
Physical Address,City,and Zip ft. 1 + ft. 1,f
21 REMARKS
County Parcel Identification No.(PIN) IAN 7 ZUZ!
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
p
N No LN, f.olt Wbclli
6.Is(are)the weil(s)dPermanent or ®ITemporary
Signature o Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair town existing well: Yes or [3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well.Constructlon 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. 0
repair under#21 remarks section or on the back of this form. k
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
�1
9.Total well depth below land surface: ;Qlgs (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing: y6 (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: (0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�t'� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f IOtL_1(19�- constriction to the following:
(Le.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:COW!)ar 1'tt1'1P_ 24c.For Water SuDDIv&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: WN d�O0/O Amount: ICAOZ 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 Revised 2-22-2016