GW1-2022-08411_Well Construction - GW1_20220510

P.,rint Form a
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information
i
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4418-A LXX 77 Ot
ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER ife lica6le
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
f� ". I go ft. /19 is 1 W
Company Name 166.INNER CASING OR TUBING(geothermal closed-loop)`
2.Well Construction Permit#: r�Hkftl©-lnl3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It. In.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring Recovery ft. ft. 01
Injection Well: - _. _ ft. ..__... "ft:
Aquifer Recharge Groundwater Remediation "
19;SAND/GRAVEL PACK'if applicable),
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additionalisheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUroek type rain size,etc
". ft
Iw
4.Date Well(s)Completed: Well ID# ft. ft
5a.Well Location: ? ft. 910 It
-
(_laokn .M 3P N rnees 7�
FaciliOwnerrName Facility ID#(if applicable) f. ft.
lirr l ft. ft.
Physical Address,City,and Zip ft. fL
n 21.REMARKS
FkX. yi:tln [iYh
County CT Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/llong is sufficient) 2 22.Certification:
t�-�--N 20 O �1 � 7•�tl W
6.Is(are)the well(s)dPermanent or Temporary Signature Certified Well Contractor Date e
By signing this form,I hereby certify that the well(s)
�coria
7.Is this a repair to an existing well: 13Yes or dNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 ell ns ,o by�f
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. AA
repair under#21 remarks section or on the back of this form. t'��.AY 1 4 2022
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 providd�o �eAt yr ✓11
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach ad g
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 395 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100D construction to the following:
10.Static water level below top of casing: (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: (D (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f- above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: T[]ftd Ato construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Ir
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) C75 Method of test: 7cae 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
1
13b.Disinfection type: 4V LOP/o Amount: J(fiBL completion of well construction to ithe county health department of the county
where constructed. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016