GW1--03357_Well Construction - GW1_20230515

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only --I.Well Contractor Information:
Gary Thompson 1a:WATER ZONES_
Well Contractor Name FROM TO DESCRIPTION
4418-A 3:3 K.: It. Pe 4D{' lI'1. »r•
NC Well Contractor Certification Number [t. fr.
IS.OUTER`CASING for multi-cased welts OR LINER if a" !fcable
Aqua Drill, Inc FROM f0 DIAMETER THICKNESS MATERIAI.
Company Name -0 ft. tt (� S in. 5}J y���
l t 36,INNER CASING.OR TUBING'( othetmal closed-loo ;
2.Well Construction Permit#: (115C'.�` pc r vti��czQ FROM zo DIAMETER THICKNESS MATERNL
List all applicable well construction permits .e.VIC,County,State,V riance,etc.) ft. ft in.
3.Well Use(checkwell use): fL ft in.
W er Supply Well: 17.SCREEN"
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural I�Municipal/Public tt ft in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft it
Industrial/Commercial Residential Water Supply(shared)
18 GROUT;
>_ Irri attOII FROM I Ti) MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: � ft. —tea ft. , , n
! Monitoring [)Recoveryft.
Injection Well:
i Aquifer Recharge oGroundwaterRemediation ft ft
Aquifer Storage and Recovery19:SAND/GRAVEL'PACK if a Ucable
OSahnity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft fL
Experimental Technology DSubsidence Control ft ft
Geothermal(Closed Loop) Tracer `.20:DRILLINGLOG attach additionaCshects ff necessa
Geothermal eating/Cooling Return) -Other(explain under 421 Remarks) FROM To DESCRIPTION(color,hardness,soilfrocktypa ra;a s ze eta
ft 1 ft (tp
4.Date Well(s)Completed: W` 4)� Well M# ft. [Dr 5 P-'-, ;c:
5a.Well Location: ft s I
rida�r�.\! �ubt GS R Gas ft
Faci[iWOwnerlkame j yn -n Facility IDff(ifapplicable) f
tk t
a J 1`iMQ`7�`blVVJ tQ Sp,,0(.11 ri���C,L' W'v ft ft ,
Physical Address,City,and Zip ft ft T
.5 `� 21 REMARKS': A n
County Parcel Identifi MA cationNo.(PIN) 1 b'2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lathong is sufficient) .•-
�v G 22.Certification:
[ `r tick. I-(Zl
N � `I• ��. �`'z l� W
Permanent or OTemporary Si rure of ertified Welt Contractor Date
6.Is(are)the wells)
By signing this fonn,I hereby certify that the Ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or �o will,15ANCAC 02C.0100 or 15A 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 ofthis record has been provided to the well owner.
repair under#121 remarks section or on the back ofthis fonn.
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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary,
drilled:
9.Total well depth below land surface: SUBN[ITTAL INSTRUCTIONS
00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(ecample-3(a�00'and 2 aQ100')
construction to the following:
Ijrvorer level is above casing,use
f Static water level below top of casing:_ �� (ft) Division of Water Resources,Information Processing Unit,
"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ray ImM/ i0�t 1— above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) lZ Method of test: C e+Ll. J"-r L, 24c.For Water Supply&Infection Wells: In addition to sending the form to
f IA"70 6 4 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: l�F 7� Amount: ��. completion of well construction to the i 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