GW1-2021-02013_Well Construction - GW1_20210620

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4418-A
tt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER If a 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MA 77 R1AL
Company Name
f
(� 16.INNER CASING OR TUBING thermal dosed-loop)
2.Well Construction Permit#: rz(4�� r �'1 a a D C) FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counh,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. tt. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) FResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. .Z-Z ft. t .
r
Monitoring IpRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology [)Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,will ck type,grain size,etc.)
v ft. 1 D ft i p
4.Date Well()Completed: 5 -� l ft. ft. r r
pleted: Well ID# tv 3
5a.Well Location: ` - ft. LA
tt. t r
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3 ► (A J) 5+a kgs t4 0 sty i-135 ft. ft. — 1
Physical Address,City,and Zip rt. ft. U� U1li�
2 p I R 21.REMARKS s a�.k�vc Irv. 79o1,�vG
County Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 22.Certification:
3�r (61 yg-, k0`76t� N 7i as—S sl,; �-.a W
6.Is(are)the well(s)dpermanent or Temporary Signature Well 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: Yes or eNo 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 ivell 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 I 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: `7 a (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(a200'and 2@100') construction to the following:
10.Static water level below top of casing: 56 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: ��tAr'1/ A / 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
13s.Yield(gpm) 7- Method of test: GOf"c� ,Tn C 24c. For Water Supply&Injection 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: h +11 70�z: Amount: Z completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016