GW1-2022-04055_Well Construction - GW1_20220422

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Gary Thompson MWATER ZONES ,
Well Contractor Name FROM TO DESCRIPTION
4418-A 10ft. 1&4 It. & UPA M016uce)
NC Well Contractor Certification Number Wa ft. U%
OUTER CASING for multi d wells)O�=a0llicable)
DIAMETER
Aqua Drill, Inc. FROM TO TER r MATERIAL
Company Name 6 ft' 66 Ca-475 in. IS% INC
f16.INNER CASING OR TUBING(geothermal closed400p) . 7
2.Well Construction Permit#: Q021(W FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
-lAgricultural [3MunicipaVPubIic ft. ft. in.
:)Geothermal(Heating/Cooling Supply) WRsidential Water Supply(single) ft. ft. is
_11ndustrial/Commercial [3Residential Water Supply(shared) GROUT
111ligation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
[3monitoring ORecovery ft. ft.
Injection Well: ft.
Aquifer Recharge [3Groundwater Remediation
,49.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwatcr Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 2 0.DRILLING LOG(attach additional Adets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION(mlor,hardness,wilfrock tyin rain size,etc.
0 ft- 1?0. "L W
4.Date Well(s)Completed: -r7-.91 well ID# It. 0 It. S4 -J"' Sol)
a-
5a.Well Location: ft % '916C `Vgnt4e-
Stu wv"
1 945 ' 'Altio 6tmnlle-
Facili,97Owner Name Facility ID#(if applicable) ft. ft.
64(al V-omecsdihe U, ldews Civele, Aic ;223co ft. ft.
Physical Address,City,and Zip
VAI' Ob
21 RENLARICS:
52L APH-z 2 2022
County 0- Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W
6.Is(are)the wefl(s)epermanent or OTemporary 9-ignTture o"fied Will 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 E�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 I GW-I 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: 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@1 OOD construction to the following:
10.Static water level below top of casing: L10 —(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:, ca 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ker above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: (Ath Je T.,fne- 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: 14TIA 70% - Amount: kanZ 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