GW1-2022-06426_Well Construction - GW1_20220510

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
90 ft. ft. t
.f'�4418-A
110 " fL 10 UPA M,,6ce)
NC Well Contractor Certification Number `45.OUTER CASING for multi-cased wells OR LINER d a' 6cahle
Aqua Drill, Inc. FROM TO DIAMETER THICKNE TERIAL
ft. L/J ft. in. � t
Company NameNQRNM
Er
16.INNER CASING OR:T.UBING eothermal dosed400
2.Well Construction Permit#: Uli � J.3 ago 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: 7.SCREEN
PP Y FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipab?ublic ft. ft in.
Geothermal(14eating/Cooling Supply) gRsidential Water Supply(single) g fL I
:11 Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_ lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: [t �►( fL
Monitoring 13Recovery ft. of�t ft.
Injection Well: ft, ft.
Aquifer Recharge Groundwater Remediation
19rSAND/GRAVEL PACK'ifs"licable -
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20i DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,miUIock a rain size,etc
t7ft-
fL
4.Date Well(s)Completed: Well ID# 20
ftOqY So.I
5a.Well Location: Ue2 ft.166 ft. I Slue- C-tl
(ar4 ,n s ��askm
Facility/Owner Name Facility ID#(if applicable) ft' ft. e
SM ►JC- 54.Gcohom . Ilse 217,961 ft. ft. r
Physical Address,City,and ip -� ft. ft.
/F'QiYlance 21.REMARKS
County 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:J
tl t u N rA0 l k, 56.6', W
6.Is(are)the well(s) Permanent or ®ITemporary Signet ret�ofCe ified Well ntractor Date
By signing this form,1 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 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
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.
If
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: SUBMITTAL INSTRUCTIONS
/� 1
9.Total well depth below land surface: (D5 (ft-) 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 rQt 200'and 2@100) construction to the following:
10.Static water level below top of casing: UL (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:�S (m.) 24b.For Iniection 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: construction to the following:
(i.e.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 27699-1636
13a.Yield(gpm) Method of test: (AACF)4'VW, 24c.For Water Suonly&Iniection 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: 14TVk?e10 Amount: `(68L completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016