GW1-2021-02226_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: IM
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A -,-3 (- &".,w
ft. fL
NC Well Contractor Certification Number .15.OUTER CASING'for multi-cased
DIAMETE FROM TO
Aqua Drill, Inc. 7 DIAMETER f��S MATERIAL
Company Name 0 ft ft. I- L. JOU e-
16.1NNERCAS1NG�.OR% ING tg6othir;niid'ddi6d466ti),---z.,;
2.Well Construction Permit#: 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): ft. ft. In
ater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3 icipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) rResidential Water Supply(single) ft. 11L
Industrial/Commercial [3Residential Water Supply(shared) 18.GROUT
I rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply W;1-1: e-
.> ft. -A-3 ft.
3Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
3Aquifer Recharge 13Groundwater Remediation
..19.,SAND/GRAVELPAC.K:tifiiObHiibliY",-,�.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLA CEMENT,METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRILLING LOG(attach additiodal sheets ifbecessary)
Geothermal(Heating/C oligg Return) 0Other(explain,under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soitfrack rain si etc.)
6 ft- I b ft. 41A L)
4.Date Well(s)Co leted: Well ID# th ft. "St) ft. nrvl� s',.'Al '501.1
ft ft i
5a.W r ia--+4
kA�c!, ft. fL
Facility/Owner Name Facility ID#(if applicable) ft.
RN 1 1=7-
SO-6 ky'.e-Ls R-S 4!iA kri, wc. ft. kjuj�'�I
Physical Address,City,and Zip ft. ft. 11
20
21.REMARKS
C g Unit
�
County Parcel Identification No.(PEN) '4'-Rpz-fosess�"'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certification:
1b N 7'7 `n-L-2,q W
Permanent or Temporary Signature cf Certified Well Contractor Date
6.Is(are)the well(s) P a� C
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: E3Yes or [ No with 15A NCAC 02C.0100 or ISA 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 I GW-I 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: -30S—
N 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: -)(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: (in.) 24b.For Iniection Wells: In addi I iion 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: rD-6E:V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I I I
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: 24c.For Water Supply&Iniectiim 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: /I 4-y' eX Amount: 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 Resou
rces Revised 2-22-2016