GW1-2022-08728_Well Construction - GW1_20220510

a Pint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES'
Well Contractor Name FROM TO I DESCRIPTION
4418-A ©k. sm ft. N
k. 11 ft NC
NC Well Contractor Certification Number .15.OUTER CASING for multi�ased wells OR LINER rf a licatile
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATRRIAI.
k. ft in. �i,J 1.08'
Company Name "'16:INNER CASING OR TUBING' eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft
3.Well Use(check well use): k. ft.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural E3 unicipal/Public k. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial [Residential Water Supply(shared) 18.GROUT
7731rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k. 5
Monitoring pRecovery ft. ft
Injection Well: k. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additionallsheets if necessary),
Geothermal(Heating/Co lin Return) 00ther(explain under#21 Remarks) FROM ft, ft TO DESCRIPTION color,hardness,wn1Mck type,grain s etc
4.Date Well(s)Completed: Well ID# 16
ft. ( ft
5a.Well Location: ' ft. 65 rt t k
ge-44� L"Y'les It-
ftlhw
,
Facility/Owner Name Facility ID#(if applicable) ft. ft
JnN Tt lsC f ► 14111g binraight &, 97,2)5r It. ft.
Physical Address,City,alff Zip k. ft
f 21.REMARKS, '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
2 59' u$.5" N V90 St 4.41t W laln-lavir—� 1 o3
6.Is(are)the weil(s)&Permanent or Temporary Si re Ce ified We Contractor 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: ®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 additiottJlfgeJiftieces .
drilled: SUBMITTAL INSTRUCTIONS ''JJ [[��
u0ppabon Proc="Unk
9.Total well depth below land surface: 60 (ft-) 24a. For All Wells: Submit this form within 30EJVp=0Qplction of well
For multiple wells list all depths ifdifferent(example-3Q200'annd 2(Qa 100) 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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
_p a� L.
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: �t, 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) d Method of test: &kb cl�-TA O- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitf one copy of this form within 30 days of
13b.Disinfection type: M TH"700/0 Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016