GW1-2022-06145_Well Construction - GW1_20220623

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Gary Thompson Ia NVA17ER ZONES
FROM I TO DESCRIPTION
Well CmmactorName NQ ft. n it
4418-A it n
NC Well Contractor Certification Number 15.OUTER CASING or multi<ased wells Olt LINER(if non liable z.•;
Aqua Drill,Inc. FROM TO DWIETER TTIICKNFSS MATERIAL
CompanyNamc I&INNER CASING OR TUBING(eothertual"dosed-loo . 'v
2.Well Construction Permit#: Q4 FROM TO DJARMTER THICKNESS I MATERIAL
List all applicable well construction permits(.e.UIC,County,Slate YarianCG etc.) ++• ft. In.
3.Well Use(checkweil use): tt ft in.
Rater SD M SCREEN
Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERGL
Agricultural unicipaVPublic ft. ft to
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) R. ft is
lndushial/Commercial OResidential Water Supply(shared) I&GROUT "
ITnigation FROM TO MATERIAL EM1TPLACEDIENT METHOD&AMOUNP
Nun-Water Supply Well: 6 tt it i)a %iy -V UbAe
Monitoring DRecovery Ft ft r
Injection Well: ft' it.
Aquifer Recharge [3Groundwater Remediation
19?SAND/GRAVEI;YACti da livable `"
:]Aquifer Storage and Recovery $allnity Barrier FROM TO brATERFAI E61Pf.ACEM1iF7iT METROD`
Aquifer Test F3StormwaterDrainage ft ft
Experimental Technology OSubsidence Control M R•
Geothermal(Closed Loop) OTracer 20:DRILLING LOG attach additional,sheets Ifnecksa :
Geodiertnal(Heatin Cooling Return) Other(explain under W21 Remarks) ""OM To DESCRIPTtON color dacdom aoiV,ock a mla cot ere
It. No neto
tt
4.Date Well(s)Completed: -54D40 Well Wit IL Ft '
So.Well Location: tt ft
InEmS
Facility/Owner Name Facility W11(ifapplicable) it. it.
j enf .Alf- r�'7�5{ rt. it.
Leia SE
� ft W�
Physical Address,City,and Zip �
21.RENURKS. . t
r�inl-�liellf�'1tt,'ml tr -
County Parcel IdentificationNo.(PIN)
S b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tfwell fiel one lat/lon is sufficient
f d, g� ) 22.Cc cation:
JG- 3;2' ;24J97-R"N —il' (411f j2J.49?04" W -�
6.ls(are)the well(s)OPermancat or OTemporary Signature o Ce died Well fbntructr Date
By signing this form.(hereby certify that the well(s)was(%era)constructed in accardunce
7.Is this a repair to an existing well: DYes or WNo with I SANCAC 02C.0100 or 15A MCA 02C.0200 NeA Construction Standards and that a
lfthir it a repair,fill out known Kell construction hrformation and eVtafn the nature of the copy ofthir recwnl has been provided to the well owner.
repair under 021 remarks section or on the bock of this fornG
23.Site diagram or additional well details:
9.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 ifnecessary_
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Qa 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple[tells fist all depths ifdifferent(ample-3Q200'and 2Qa 1003 construe to the following:
10.Static water level below top of casing: ago (it) Division of Water Resources,Information Processing Unit,
If water ictel u abme caring;use"•t•' 1617 Mail Service Center,Raleigh,NC 27699-I617
11.Borehole diameter. (a (!D.) 24p.For inicetion 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: .'r construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) .
Division of Water Resources,Underground Injection Control Pro•„ram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) 5 Method of test r .zT�h Ton. 24c.For Water Supply&inlection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1i71a�lo°lo Amount. tGol completion of well construction to the,county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
1 of 1 6/23/2022, 12:31 PM