GW1-2021-02307_Well Construction - GW1_20210722

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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 Contactor Name y t t IL r
4418-A 1'-1 r
ft. ft. I
NC Well Contractor Certification Number Wed15.OUTER CASING for multi-casedwells OR R a livable
Aqua°°Drill, Inc. FROM TO DIAMETER THI=ss MATERIAL
Q ft. ft in. % /'
Company Name 16.INNER CASING OR TUBING eothermalfelosed loo l•
2.Well Construction Permit#:Ga-): MC-0 i olvo—lb-Lb FROM TO I DIAMETER I THICKNESSLMATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Vatiance,etc) ft. ft In.
3.Well Use(check well use): ft. ft in.
Water Supply Well: FR M REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft
Geothermal(Heating/Cooling Supply) FeRsidential Water Supply(single) ft ft io
Industrial/Commercial Residential Water Supply(shared) 1&GROUP
']Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: nft. ft `
Monitoring DRecovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
1_319.>SAND/GRAVEL<PACK it:ii_"livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.:DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other lain under#21 Remarks) FROM To DESCRIPTION(color,bards soil/rockrain e' etc
n ft. I; tt i ,
4.Date Well(s)Completed:Cn lQ_d} Well lD# ft. ft
Sa�Well Location: ft ftj
aft c' 2.\\,o l�� '70ft
c It t
Facility/Owner Name
,��, - G_ Facility ID#(if applicable) ft' ft.
4;XU J Ag' (1�, '&4 je&r Ly— fL ft c"
Physical Address,Ct'ty,and Zip ft. ft t
21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: <<�
(if well field,one lat/long is sufficient) I J 22.Certification:
t&2 ly OCa. iN $Gd • $ LVII.� Nas W ` G•1 o d -I
6.Is(are)the well(s)dPermanent or Temporary Signature o e 'fled We Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or dNo with 15A NCAC 02C.OI00 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#11 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: (ft-) 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: yO (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: ca (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
L�C above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Uiiderground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: `_ _`.-� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 104 Method of test(Ak\"� lt9' 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HYN Amount: completion of well construction to ithe 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
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