GW1--05803_Well Construction - GW1_20230901

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: ;WELL form
1.Well Contractor Information: I I
Gary Thompson 14.WATER ZONES II I
1
Well tContractorName FROM TO DESCRIPTION
4t18-A �t�.�1 ft' 7.ZZ ft' r.PL�'j���� ('?ptM
NC Well Contractor Certification Number 3 QC ft' p '11- ^+"��,T° (>y ire`
15.OUTER CASING(for multi-cased welts)OR LINER(if Hp licable)
Aqua Drill, Inc FROM TO DIAMETER. THICKNESS MATERIAL
Company Name <, v 0 ft. I s-zi ft. I C. 3 in. 15,E f,.Z` I p 4...S(12
16.INNER CASING OR TUBING.(neotliermal dosed-loop)-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. i in.
3.Well Use(check well use): ft ft in,
Water Supply Well: 17.SCREEN
A Cnitlllal FROM- TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn DMtmicipal/Public ft. ft. in.
[Geothermal(Heating/Cooling Supply) Elf esidential Water Supply(single) R. ft la.
RIndustrial/Commercial [Residential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: it. ft. /1 t
LIMonitoring Recovery ft. �4Q ft. 1.9ew6s,..s C b1•,,.r' k-vo.
Injection Well: t`t`'3'S
Aft.Rechargeft ft
q fGroundwaterRemediation
A offer Stor a and Recovery19.SAND/GRAVEL PACK(If applicable)
Storage g OSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
QAquifer Test IDIStormwaterDrainage ft. ft.
I.
DExPerimental Technology I Subsidence Control ft ft. '
QGeothelmal(Closed Loop) IOTracer 20.DRILLING LOG(attach additional sheets if necessary), -: •
DGeothermat(Heating/Cooling Return) rOther(explain under#21 Remarks)• FROM TO DESCRIPTION(color,hardness,soi0rock type,grain she MO
b e* l tb t:. CA ri v
4.Date Well(s)Completed:44- -23 Well ID# La R' LI S ft. Pr i S a •i 5 p r,
5a.Wen Location: wr ft �e, ft 1' 7 1 /
o rtoir. rr'
eft;kL Skt3Nv t e.`l Sv ft. ft
3ir'' f,cur:.‘-,_
Facility/Owner Name Facility ID#(if applicable) ft ft. I ,,, 9- ....
+C1 � 1t eJ q O 1 wesk' Cjltest- ,t.c dL me ft. ft. i t \3-,'�..'s e v a-,rw .
Physical Address,City,and Zip ft. ft. S p P V l i ri L O 23
5 k,GS 21.REMARKS.
County Parcel Identification No.(PIN) lrt`^f5,�:tdl1 t�f. }'�'wl' l f`
DV`aCti,1S0vr
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) - 22.Certification:
GZq I I Z 6 OSO4" N itf g' (As a. -°T'L1/ W �,(�� n -
i.
6.Is(are)the well(s) rmanent or Temporary Signature ofCent Well Contractor , Date
By signing this form,I hereby certiO that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (JYes or DWI with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out(mown well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under 021 remarks section or en the back of thisform.
23.Site diagram or additional well details:
S.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: 1 Z (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths If different(example-3Qa 200'and 2®100) construction to the following: 1•
10.Static water level below top of casing: 1.05 (ft.) Division of Water Resources Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
• 11.Borehole diameter. 4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
• above,also submit one copy of this foim within 30 days'of completion of well
12.Well construction method: f'b4Itt ry 0. / construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,UDderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Za Method of test: --M�`��4 f''��- 24c.For Water Supply&Infection Wells: In addition to sending the form to
l� l� d,• r the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: `1 bit, Amount: V / completion of well construction to the county health department of the county
where constructed, j
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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