GW1-2022-04031_Well Construction - GW1_20220422

Print Form ._
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contractor Information:
Gary Thompson ;14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A ft. 1 ft. e , u
NC Well Contractor Certification Number a ft. 77 ft 13 Jq' e)
15:OUTER'CASING for multi cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. I �Ih C
Company Name 16.INNER CASING OR TUBING eotheemal'closed400 YV
2.Well Construction Permit#: �� FROM TO DIAMETER THICKNESSDIATER[AL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well: >
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [I unicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft in.
Industrial/Commercial DResidential Water Supply(shared) :18:GROUT -
lrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. o 5 ft. t '
Monitoring DRecovery ft. ft
-Injection Well: -
ft. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and RecoverySalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft.
:)Experimental Technology DSubsidence Control ft ft
BGeothermal(Closed Loop) (©ITracer 20:DRILLING LOG attach additionatsheets if necessary).
Geothermal(Heating/Cooling Return) ! Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
/�
ft. q ft
-e. 1-110
4.Date Well(s)Completed: L1- 1Q Well ID# CIO ft. c It. v
5a.Well Location: 60
ft. ft (� U .
te
li('"Cf►(1 f]t1 t'i Jt2 ft 4
Facility/Owner Name Facility ID#(if applicable) ft. ft.
6,011 C 1AW9 704 L MW'6,on 1)L,@-7a5 ft. ft APR 2 2 2022)
Physical Address,City,and Zip ft ft
lit7Y1� 21.REMARKS
1,:157i. „,,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) C1 22.Certification:
6.Is(are)the well(s)EPermanent or IOTemporary Signa re o I
Ce rfied Well Contractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing wen: nYes or �No 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 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
t
9.Total well depth below land surface: y (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: Lb (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: co (in-) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n ! (l, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: '1n1t1 Yt E 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) 5 Method of test: 1,0np_ 24c.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: '1100/0 Amount: I(GAz completion_of well construction to'the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016