GW1-2022-05800_Well Construction - GW1_20220615

Pflnf Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATERZONES;,
Well Contractor Name FROM DESCRIPTION,
4418-A silo R. 14 f` e
ft. ft.
NC Well Contractor Certification Number 15.:OUTER CASING formMlfi�ased veils ORLINER da' Hcable:.
Aqua Drill, Inc. FROM (Oil
DIAMETER THICKNESS MATERIAL
Company Name © ft (t/ R (Q In. YVc
i6:INNER CASING OR-TUBING eotliermal.closed400"
2.Well Construction Permit#: ©o?�O FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) ft
3.Well Use(check well use): ft. & in
W r Supply Well: 17.SCREEN•..:.
FROM TO DIAMETER SLOT SIZE, THICKNESS _MATERIAL
Agricultural OM[unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft-
TO in
-:Industnal/Commetbial DResidential Water Supply(shared)
18..GRODT _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fL IL of Mrdk
Monitoring .- Recovery ft. ft.
Injection Well:
Aquifer Recharge Groundwater Remediation R ft 19.SAND/GRAVEL PACK rf a' livable
Aquifer Storage and Recovery DSahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
-'Aquifer Test 0 Stommwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer s.20.DRILL'INGLOG attach additionidlitieetsifnecess
Geothermal(Heating(Cooling Return) ! Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillmck a ue rain s ,etc.)
- R. O tt
4.Date Well(s)Completed:(0-16-,Z2 Well ID#
5a.Well Location: 1 f R it
!1~T19t11r1S4iE tS ft AZ ft ^,
Facility/Owner Name Facility ID#(if applicable) ft
X80 CnMefe_4 Jvj�wal Hall, )c a? tfi. IL � P
Physical Address;City,and Zip ft ft y
�h21.REMARKS`_
County 07 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
O t h C r id,
N Wes' �CJ 50•g W Lf
6.Is(are)the well(s)dermanent or 'OTemporary Signature ofC red Well Co tractor Date
�No
By signing this form,I hereby certtfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 wider#21 remarks section or on the back of thisform. 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
9.Total well depth below land surface: 3ra -(ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For mtdtrple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (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: (10 (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
n A above,also submit one copy of this form within 30 days of completion of well
Cie Well can struction method: Y Y Hi('
(i .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) 95 Method of test: Cgkh+r;Me 24c.For Water SuDDIv&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:-UT147CPIQ Amount: 160Z 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