GW1-2021-01435_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
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Gary Thompson .14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4498-A ..�,T ft. � tt. rtit„-}a'•- 1 a ���—'
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER ifa- licable -
Aqua Drill, Inc. FROM ITo DIAMETER I THICKNESS MATERIAL
D ft. j 5- ft. G i l in. 5 iD:=, A` '9 u�—
Company Name 16.INNER CASING OR INGlaeothermal closed-too
2.Well Construction Permit#: oZl -8 -to-)N {•."aka G 4IA FROM To DIAMETER I THICKNESS MATERIAL.
List all applicable n0 construction permits(i.e U1C,Coruav,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. tL in.
Geothermal(Heating/Cooling Supply) rR sidential Water Supply(single) tt ft In.
Industrial/Commercial DResidential Water Supply(shared)
1&GROUT
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FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: t. ZY ft. .'w L,.,. �L, t u.Lg Recovery ft. frell: fr. ft.
echarge DGroundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence'Control ft. ft-
Geothermal(Closed Loop) [)Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatingtCooling Return) 00ther(explain under#21 Remarks) FROM 8 fr. iL ss.To DESCRIPTION color,hardne soiu,o¢k rain size,eetc.)
4.Date Well(s)Completed: Well ID# ft. L+ ft.
5a.Well Location: 1 \ fL rC ft.
ft. IL
Facility/Owner Name Facility rD#(ifapplicable) ft. ft.
`!61r<C 1�lot.,,P r i-J- It.11 V.'S<.- 2- 1Z•LLV� ft. ft.
Physical Address,City,and Zip ft. ft
21.REMARKS
VS ,�)ICJ _ pCOG
County Parcel Identification No.(PIN) R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladlong is sufficient) 22.Certification:
6.Is(are)the well(s)OPermanent or OTemporary, Sliekturco CelfiffiedWeffContractor Date
�� Bp signing this form,1 hereby certify that the twil(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or O with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that
/fthis is a repair,fill out knotm well construction information and explain the nature ofthe cop),ofthis record has been provided to the well mvner.
repair under#21 remarks section or on the back ofthisform. 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple hells list all depths ifdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 b (ft.) Division of Water Resources,Information Processing Unit,
lfivater level is abate casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6
m.)
( 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: e-jA construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
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Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) �a Method of test• C h�a�` I t'Y�,z 24c.For Water Supply&Iniection Wells: In addition to sending the form to
r? = G the address(es) above, also submit o farm within copy of this far within 30 days of
13b.Disinfection type: 7 a/St Amount: G �Z 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
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