GW1-2022-04049_Well Construction - GW1_20220422

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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 I DESCRIPTION
4418-A
070fr. ft. 9
NC Well Contractor Certification Number 4 1p ft. Lill
It-
t 4&PR/'V r
15:0UTER CASING for'multi-cased:3vells OR LINER"d a licable"`
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0
fr. ll ft- F,ryC in-
5e[vf)al �UG
;16'INNER CASING OR-•TUBING eother"mal'clotsJedrl-loo
2.Well Construction Permit#:_�(e�� 'S Ai -���� 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 []Municipal/Public ft• ft. in.
Geothermal(Heating/Cooling Supply) ffRsidential Water Supply(single) ft. ft. in.
Industrial/Commercial i- Residential Water Supply(shared) :-:18 GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. �OC tt. me to4h -rru K
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge IOGroundwater Remediation
.;"49.SAND/GRAVEL PACK.if a -6cable - - - '
Aquifer Storage and Recovery DSaliuity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorinwater Drainage ft, ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRII:LING LOG"attach additioifal'sheets if uecessa
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVrock type,grain size,etc.
fr. ft �'
au
4.Date Well(s)Completed: �.a3 P Well ID# ft U® It. ,
- 5a.Well Location: 140 ft. 110 ft t
WQlap Ct Oup 110ft. 116 It.
Facility/Owner Name Facility ID#(if applicable) 1.1,5
ft. It-
ft. ft. 7J
9�09 Je�c� 1 Acres /Dr, Sctr►m�_r e�J,.l)c �?735�
Physical Address,City,and Zip ft. ft.
1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laVlong is sufficient) 22. a 'fication:
6.Is(are)the well(s)&Permanent or OTemporary Signature ofC&1ified Well Co tractor 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 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: @@'',rr�� SUBMITTAL INSTRUCTIONS
`7n1 9.Total well depth below land surface: 5 (ft) 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@100� construction to the following:
10.Static water level below top of casing: (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: (9 (in.)) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�j O�a /i�C above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f1 construction to the following:
(Le.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 276994636
13a.Yield(gpm) 5 Method of test:rjACh", 1,'fne 24c.For Water Supply&Injection'Wells: In addition to sending the form to
NTH the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: 1-I 11-t ���0 Amount: ��662 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