GW1-2022-03038_Well Construction - GW1_20220228

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well,Contractor Information:
Gary I nompSOn 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A
ft. '` '
r
NC Well Contractor Certification Number 0��k. ` ft
15.OUTER CASING for multi-cased wells OR:LINER if III vable
Aqua Drill, Inc. FROM To DIAMETER THICKNESSMATERAAL.
ft. Y/C ft. in.
Company Name
�g } T r79 7n '16.INNER CASING OR TUBING' eothermal-closed400
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2.Well Construction Permit#: 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. It. In.
i
3.Well Use(check well use): ft. ft. in.
SCREEN
Water Supply Well: 17.
FROM TO DIAMETER i SLOT SIZE THICKNESS MATERIAL.
Agricultural 13 Imicipal/Public ft. It. in
Geothermal(Heating/Cooling Supply) Residential 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. fL 4- N
3 Monitoring Recovery ft. ft. 07
Injection Well:
Aquifer Recharge Groundwater Remediation
`19.SANDD ft
/GRAVEL PACK if a' Hcnble
L=NAquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) -Other(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness,soillrock in size,etc.
rt Icy
4.Date Well(s)Completed: - 0-OO Well ID# It. ® ft ,1
5a.Well Location: U0 ft. T70—ft Pt So c,
(� n -rAo ft. '7-5
It
�A(iAIt�IQ CL1S{tlnt$ f77 L�LfC��(�n
Facility/Owner Name (/// Facility ID#(if applicable) ft-
Oy ft.
_7 2!2 i A44a JPW POAC-C-1500 I AJC 97537 fL ft.
Physical Address,City,and ft. ft.
21.REMARKS
-6&tnymi� VaSlee-
County Parcel Identification No.(PIN) UrA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the wells)&Permanent or [3TempoWrNo
Signature o Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or with 15A NCAC 01C.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 1 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: I OGJ (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@2010'''and 2@100� construction to the following:
10.Static water level below top of casing: 4o (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"/!+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: LQ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n dr above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ey /tr` construction to the following: i
(i.e.auger,rotary,cable,direct push,etc.) p
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:fc CY) cA-T1%fAe 24e.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: W" '70% Amount: 1co OL. completion of well construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016