GW1-2022-03834_Well Construction - GW1_20220331

,Print Form_ �.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
k.
4418-A
k. ft.
NC Well Contractor Certification Number ;15:OUTER CASING for mulfi casedwells OR LINER,if a licable i
Aqua Drill, Inc. FROM TO DIAMETER THICIavEss MATERIAL
o k. 68 ft. f-.A in-
Company Name 16 INNER CASING OR TUBING. eothermal closed loo" c:
2.Well Construction Permit#: -;dr!XQ LawJ g1 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
Agricultural [3 unicipaVPublic k. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. k,
Industrial/Commercial Residential Water Supply(shared) @
18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k. ft. 4Monitoring Recovery ft. ft.
Injection Well:
k. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL',PACK.,'if;e"licable r v
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 additional sheets if necessa
Geothermal(Heating/Cooling Return)[- Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiltrock %grain size,etc.
A�^^ O k. ft. t
4.Date Well(s)Completed: Well ID#
5a.Well Location: 573 5 ft1,111, ay
n 1,�t1, ft. (0�5 fL ,
i14tl�f Cn�S "ary. me 5
Facility/Owner Name Facility ID#(if applicable) k. ft.
Physical Address,City,and Zip k. fL n
21.'REMARKS
a>j��
County Parcel Identification No.(PIN)
. i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat11ong is sufficient) 22.Certification: 1`' !'
35° 53' 414" N 'M'* 3d ya.�'' W
6.Is(are)the well(s),7(permanent or Temporary Signa ure of ertified Well ContActor 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: [3Yes or No with 15A NCAC-02C.0100 or 15A NCAC 01C.0100 Well-Construction Standards and that a
If this is a repair,fill out known well construction information and explain the native 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: ^ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: lay (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 2@100) construction to the following:
1
10.Static water level below top of casing: 95 (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 Iniection 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: ke construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) IT Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
r1 is
13a.Yield(gpm) °1n Method of test:(AC)(1 4 Y:Me 24c.For Water Supply&Injection Wells: In addition to sending the form to
j, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type' FiI" W/iN Amount: VahL completion of well construction to`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