GW1--03251_Well Construction - GW1_20230511

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: -Print Form
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A Y6ft. ( ft �rpc�> G Gpn
ft. ftNC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells LINER a licable
Aqua Drill, Inc FROM TO DIAMETER OR THICKNESS I MATERIAL
Company Name (� ft. 41 5-ft a+ytis in. 51J �� UL
�A `-16.INNER CASING OR TUBING eothermal closed-loo •
2.Well Construction Permit FROM I To I DIAMETER I THICKNESSI MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft is
3.Well Use(check well use), ft. it in
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS atATER1AL
Agricultural EQIMunicipa]/Public ft. ft in.
Geothermal(Heating/Cooling Supply) b<eQential Water Supply(single) ft. ft. In.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: IL ft r
Monitorin — ' r'�''FS
g Recovery ft. ft. Ck l M
Injection Well,
ft. ft
Aquifer Recharge ,oGroundwater Remediation
79. AND/GRAVEL
Aquifer Storage and Recovery QlSalinity Barrier FR S PACK if alicable
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test I©IStormwater Drainage ft ft
Experimental Technology Subsidence Control ft. ft
3.Geothermal(Closed Loop) DTracer 20.DRILLING'LOG attach additionatsheets If necessary)
Geothermal(Heating/Cooling Return -Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,s Wruck e, rain size,etc.)
ft. ,b ft
4..Date Well(s)Completed:LA-_"k_1:!' Well ID# It. ft
th ti ;e:,r l
5a.Well Location: [� `r D ft, '7 ft
rL�YaS �`�13NY\� f'ak•u, �y ft. ft. Gr01i
Facility/Owner Name �— Facility ID#(ifapplicable) ft. ft
S�yU (n'ic.rr�l ft
11 1 o'e%y V
Physical Address,City,and Zip ft ft
I_ HREMARKS `' Cn " �+
or-SV rk
County 1 - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one lattlong is sufficient) eat 22.Certification:
y j
W —�tl�so -yt/1✓ `7`-�.�"a,�j
6.Is(are)the well(s). 'ermanent or E3Temporary Signature of ertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or 03<o with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record hae 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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 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'and 2@100D construction to the following:
10.Static water level below top of casing: b (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
�° above,also submit one copy of this form within 30 days of completion of well
M'C'bc-�/ r'
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:T
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) (a Method of test Cakcl.7��:`+"� 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
13b.Disinfection type: TN�O Amount: l��� 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