GW1-2021-02310_Well Construction - GW1_20210722

y.;r Print Form
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 ft' SS f` �,elr'_`o /sr^
NC Well Contractor Certification Number i 15.OUTER CASING for mu sedwells OR LINER' e' licable
Aqua Drill, Inc. FROM To DIAMETER THICIINESS MATERIAL
Comp.'any Name -o ft. , Z ft. G.L j iR. -50A L l it
"16.INNER.CASING OR TUBING eotheimafdosed+loo '
2.Well Construction Permit#:W SA` '9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, c) ft. f4 In.
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural tmicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. it. in.
Industrial/Commercial DResidential Water Supply(shared) ]&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t;�n Z Z f i h, y,r�E r G�,,t ,y
41
Monitoring Recovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
I91-SAND/GRAVEL PACK if ii ii Ileable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRII.LING LOG'attach additional sheets if necessa
Geothermal(Heating/Cooling Coolie Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sotoroek eta
a ft- 1 b f` � l
4.Date Well(s)Completed: — ,ZI Well ID# ft. f`
5a.Well Location: \ S f 41 ft. trim
��z`r S7r�Aw 1 ft.
Facility/OvAer Na a Facility ID#(if applicable) ft. ft.
,tea-
t t�i� l'�Jd. Z7CSJ � �
L�f"'C. 1'`Cs/ rk.�u
Physical Address,City,and Zip ft. ft.
21.REMARKS
Co ty Parcel Identification No.(PIN) %
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hit/long is sufficient) is 22.Certification:
2e IJ'01 . S'i-7V t N 35�$ IG4 l� W 4 _2 �
6.Is(are)the well(s) rmanent or 131remporary Signature ofCahifiid We ontractor 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 No with ISA 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: AS//�� 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 ifdifferent(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: 7i (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 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: r0 4'y Ai V— construction 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) a Method of test: ` 24c.For Water Supply&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: kkkl 0 Amount: r L a� completion of well construction do 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