GW1-2022-05590_Well Construction - GW1_20220614

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information:
i
Gary Thompson 14.WATER ZONES f
FROM TO DESCRIPTION
Well Contractor Name
ft. i
4418-A ft III)ft 6 URN " a e
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER d a licable
Aqua Drill, Inc. FROM to DIAMETER THICKNESS MATERIAL
Company Name O It. 6© ft CQ 95 in.
�1 .16:INNER CASING OR TUBING(geothermal dosed-loo
2.Well Construction Permit#:` W1 I,..n 2C?t`�l9t'.9Ck'?56 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.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 ISLOT SIZE THICKNESS MATERIAL
Agricultural D; unicipal/Public ft. ft. in.
rm Geotheal(Heating/Cooling Supply) , Residential Water Supply(single) ft ft. in
Industrial/Commercial ID-Residential Water Supply(shared) 18.GROUT_
_ IrrigatiOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: r -
Monitoring DRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery iQL_Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control it ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG`(attach additional sheets if necessary)
Geothermal(Heating(Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardams sojl/rocktype in size,etc)
ft. ft
4.Date Well(s)Completed: 5-19-029 Well ID# +' ft. (co ft.
5a.Welt Location: ft �75 ft
Lax fA mchxky�
/ ft. o' ft. •
Facih ryOwner Name Facility ID#(if applicable) 96. ft J It.
� b CJtC➢Pif� kand-1 yMC 1AX M(307 ft ft.
Physical Address,City,and Zip ft. ft -
swnj 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t��a� ��+ 1
(if well field,one latfiong is sufficient) 22.Certification: PRVtrL`a7v'irt1V UNP
6.Is(are)the well(s)&Permanent or DTemporary Si use ofCer' ed Well Contracjbr Date
By signing this farm,1 hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or WNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction.Standards and that a
Ifthis is a repair•fill oa known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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-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: 3z (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths ifdifferent(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: L10 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use
//+- 1617 Mail Service Center,Raleigh,NC 27 69 9-1 61 7
11.Borehole diameter: lS (in.) 24b.For Infection 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: •1 too.o A:5 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: y 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: rkh a-Tahe 24c.For Water Supply&Injection Wells: In addition to sending the form to
�ii .�I / t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 11�(� ld0i0 Amount: I[trfl' 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