GW1-2022-03846_Well Construction - GW1_20220331

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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
ft. ft16G .
4418-A A50
ft. ft.
NC Well Contractor Certification Number 15.-OUTER CASING for 7ulti-cased'we11s OR"T INER`'if'a' licabie'
Aqua Drill, Inc. FROM TO DIAMETER THICKINESS MATERIAL
Company Name O ft "" ft .;25, ra• ill �UC
�tc� "16.INNER CASING OR`TUBING eothermiil elosed-loo
2.Well Construction Permit#: �/ FROM TO DIAMETER j 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 unicipal/Public • ft. in.i
Geothermal(Heating/Cooling Supply) R ft
esidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
4 Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. fL ,
Monitoring DRecovery ft. ft.
Injection Well:
ft. it.
Aquifer Recharge 13Groundwater Remediation
19::SAND/GRAVEI1-PAGK;if.a"`Iicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach_additional iheets if necessa
Geothermal(Heating/Coohn Return) 00ther(explain under#21 Remarks FROM ft. TO
TO DESCRIPTION(eolor,hardness,soillrock rain s' etc.
�fn
4.Date Well(s)Completed: �' 'atnc Well ID# ft. ft i `
5a.Well Lo�c�a`tion`: -63_ ft. 15y ft
r ►►ne I"�HCSflt11� $ ft. 195
fL ,
Facility/Owner Name Facility ID#(if applicable)
ft. ft ! J.-
MAR 31
CeCo S �e;Pf�sr�o . LtPrmas any NC �9b19 rt. rt 21
Physical Address,City,and Zip ft. ft.
7Tfyf1L'� 21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22.Certification:
_%o ifs' L10 It N 90° 151 15.3" W I a
r�r•
6.Is(are)the well(s)dPermanent or EITemporary Signature cf Certified Well Contractor 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: [3Yes or dNo with 15A 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 ofthis form. .
:
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: (ft-) 24a. For All Wells: Submit this'Iform within 30 days of completion of well
For multiple wells list all depths if different(example-3(@200'and 2@I00) 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"t+�" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CD (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n ' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f1BtwW Ar construction to the following:
(i.e.auger,rotary,cable,direct push,etc k
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: t. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 55 Method of test• Ca keh T;m►e 24c.For Water Supply&Iniection 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-TJJ -30P10 Amount: I GOl2 completion of well construction to ithe 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
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