GW1-2022-08417_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 I k rrt r� � ce
NC Well Contractor Certification Number '1, k. Pq't f 4 8 COA � i C
15.OUTER CASING for multi cased wells OR LINER a Hcable
Aqua Drill, Inc. FROM TO LIMTER TffiCIQVESS MATERIAL
on ft. It. G•'A in.
WC
Company Name 16.EWER CASING:OR'TUBING' eothermal closed-loop)
2.Well Construction Permit#: 3lD W FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) k. fL In,
3.Well Use(check well use): ft. fL r°•
SCREEN
Water Supply Well: 17.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E unicipal/Public ft. ft. in.
:)Geothermal(Heating/Cooling Supply) Residenti. al Water Supply(single) fa ft. i°•
IndustriallCommercial 13Residential Water Supply(shared)
>18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
Monitoring DRecovery k. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock rain size,etc.
Geothermal(Heatin Coolin Return) Other(explain under#21 Remarks) y0 ft. eL. ft. CAU
4.Date Well(s)Completed: Well ID# G ft. _:. tt. MW
5a.Well Location: ft, 51f ft'
chs;S&& UMW -ekN g ft. fL 140- G-tcun
Facility/Owner Name l /(�� y rt Facility ID#(if applicable) ft. ft.
�► 1Riirrr�tlS•40 � Je,J II%©�� ft. tt.
Physical Address,City,and Zip 4' k. ft (�22
Sao 'S 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one t/lat/lon�g is sufficient) /1 22.Certification:
3C® ; uW Isler N AQo MY _5�.9'r �'► 1d14 XEMq Aa�
6.Is(are)the well(s)dPermanent or 13Temporary tgnature df CVfified Wen Tractor 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: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
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.
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: nC SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5"?-5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'aandd 2@I00� construction to the following:
10.Static water level below top of casing: io (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: (0 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
JA�, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ax q /i rr; 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) '7 Method of test: -T:411t 24c.For Water Supply&Iniectioni 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: JAW !no Amount: 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