GW1-2022-08414_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
Well Contractor Name FROM TO DESCRIPTION
4418-A
ft ?I1 ft
e7!1 • ft. . ft. Yi ,
NC Well Contractor Certification Number 15./OUTER CASING for mu17d cased wells OR LINER tf a" 4cable
Aqua Drill, Inc. FROM To DIAMETER THICIQYESS MATERIAL
Company Name Q It. u0 ft ✓15 in. Col-91
16ANNER CASING OR TUBING, geothermal elosed400)
2.Well Construction Permit#: t C�7 R THICKNESS MATERIAL
FROM TO DIAIVIETE
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: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13 ft unicipal/Public . ft in.
Geothermal(Heating/Cooling Supply) ffRsidential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
>18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: It- .23 it ,{e ,4- (
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
_19.SAND/GRAVEL"PACK if Applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional(sheets if hecessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/mck a rain size,etc
�t�1 0 ft. fL
4.Date Well(s)Completed: u-11- Well ID# ft. ft
5a.Well Location::' ft u ft 1
C6KI.�d Wmme-S 140 ft. 306 tt
Facility/Owner Name Facility ID#(if applicable) ft. ft
.g OaK 'b r).&ecman4nn.,,11s. Zo19l k. ft
Phy al Address,City,and Zip ft. ft
21.REMARKS CW.,,.
90&5
County Parcel Identification No.(PIN) ��
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
n
6.Is(are)the well(s) _Permanent or Temporary Signa ofCe ied Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or dNo with 15A NCAC 02C.0100 or I5A NCAC 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 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 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: 365 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 4Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use//"+ 1617 Mail Service Center,Raleigh,NC 27699=1617
I1.Borehole diameter: l4 (in.) 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: 1 atCh tiW 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�1
� the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: H��I ��3` b Amount: le o: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016