GW1-2022-02997_Well Construction - GW1_20220228

Print Form ,
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A 7 ft. 1q fL L1 94
O ft. 9%71 fL &P e
NC Well Contractor Certification Number a15.OUTER CASING for multi-cai:ed wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. �in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Tax �$_ICCP�•y
FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.WC County,''late,Variance,etc) b ft. tl© ft. Ito , INC
3.Well Use(check well use): ft. ft. I in. f
Water Supply Well: 17.;SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 1e.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. tL R1
Monitoring Recovery
Injection Well: -
fL ft.
Aquifer Recharge Groundwater Remediation
19:;SAND/GRAVEL-PACK'if-a lieatile i M.x#..as = 'n
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.DRILLING LOG attach additionalsheets if necessary)
Geothermal (Heating/Cooling Return) ,Other(explain under#21 Remarks) FROM ft TO DESCRIPTION color,hardo soil/rock type,arain size,etc
4.Date Well(s)Completed: ('Oua Well ID# ft. fL
5a.Well Location: ft. ft. t
(Jo"d"M C-L, 40ms c s���j t ft. 795 ft
Facility/Owner Name Facility lD#(if applicable) ft. ft.
Physical AddressvCity,and Zip ft. fL
Z1.REMARKS
County Parcel Identification No.(PIN)
r IJWQ )G .
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,,,one lat/long is sufficient) 22.Certification:
7In0 95' !jaart N 280 57' 4.5tt W
6.Is(are)the well(s)[dPermanent or 13Temporary Sign. re of rti ed a Contactor 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: 13Yes or [dNo with 1 SA 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 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: e SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _) 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 40 (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: CQ (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: P 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
13a.Yield(gpm)_�e Method of test: C[tkY1 24c.For Water Suonly&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 1-�`1'1 '?polo Amount: (ftw- completion of well construction to the county health department of the county
where constructed. C
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016