GW1--05937_Well Construction - GW1_20230918

Print-Form WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �-
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
a
Well Contractor Name FROM TO DESCRIPTION
4418-A SOb ft. .. i ft, ci..;E;ti I. IA Li,Se"
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc Is:OUTER CASING(for mult'cased wells)OR-LINER Of ap 7icable)
FROM TO DIAMETER THICKNESS MATERIAL _
0
Company Name I G '' It. I 4I).-7" in. S)P- 1 p t.)c
gg�� .�.� ,16.1NNER CASING OR TUBING(geothermal closed-loop) =
2.Well Construction Permit#:04. �p,57 "' i� ,.h FROM TO DIAMETER THICKNESS MATERIAL
List all applicable u'ell construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well:. 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
icipal/Public ft ft. in.'
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial C3Residential Water Supply(shared)
•IS GROUT a.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: -6 ft. —1.4> ft e e
Monitoring Recove `�°t'�1e elm( ' 44?�.
Injection Well: ry ft. IL CAI l $
Aquifer Recharge DGroundwater Remediation ft '
Aquifer Storage and Recovery l�ISalinity Barrier „19.SAND/GRAVEL PACIC(if applicable). -
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [ Stormwater Drainage ft. ft.
Experimental Technology E3Subsidence Control ft. ft.
•
Geothermal(Closed Loop) OTracer -20.DRILLING LOG(attach additional sheets:if necessary)
Geothermal_ FROM TO DESCRIPTION(color.hardness, oa/roctc
(Heating/Cooling "�Other(explainunder#21Remadcs) type,grain are,etc.)
eY f� 1- ft. l47 ft. t��
4.Date Well(s)Completed: .�l'"*" Well ID# 11 D ft. 7 S- ft
5a.Well Location: ' 5 ft• �,, 1 4"-t '
Z-01�,W .1.�.N i-v)' S Z ft. 5-4,, ft. G.`toe.: I-€
Facility/Owner Name,. Facility 1Dft(if applicable) ft. ft.
AI k l)`t! Aa Y L ;-J 1.-t l tap vki. J 4 1`6:- tt ft [ r„ .. s Eo"�`'h x
Physical Address,City,and Zip ft. ft. I
2L'REMAR(s - n
' �� �'�' tiFr . ,. 2C23 ,
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r;, ;Cj1S;
(if well field,one lancing is sufficient)
.y 6 1 ) gp 22 Certification:
. I( pie "fci ao) N e76+)3.9/ i •
1/zap. _� 7— 9) 1.
6.Is(are)the well(s) ._ Permanent or JITemporary Signs re o Certified Well Contractor Date
By signing this form,l hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or De.
with ISA NCAC 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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
vQi
9.Total well depth below land surface: se-
( )
For multiple wells list all depths ifdi different(example-3@200'and 2@I00) on c For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: ft
If water level is above casing,use"+ ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4, (id)
24b.For Infection Wells: In addition+to sending the form to the address in 24a
rl (2; .^ above,also submit one copy of this',form within 30 days of completion of well
12.6Ve11 construction method: (`d$i r
(i.e.auger,rotary,cable,direct push,etc.)
t 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) �. �7— Method of test: CA44.)--4 i 1"h r 24c.For Water Supply&Injection Wells: In addition to sending the form to
t> ✓a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Cal 4 11 4 f1, Amount 1(° ✓ 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