GW1--06190_Well Construction - GW1_20230922

WELD,CONSTRUCTION CORD(G�1 I Print Form
For Internal Use Only:
1.Well Contractor Information:
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Gary Thompson t ,i
14.WATER ZONES i 1
Well Contractor Name FROM TO DESCRIPTION
4418-A S QSft. S-"x-? f• t-`ft.6a r 41 i 6.71+
NC Well Contractor Certification Number ft.
Aqua Drill, Inc IS.OUTER CASING(for multi-eased wells)OR LINER(tfap Iicable)
FROM TO DIAMETER I THICKNESS I MATERIAL
Company Name a ft. S ft. I (rIZ,. in.
[' 2 D ') Pry
16.INNER CASING OR TUBING(geothermal dosed-loop)
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2.Well Construction Permit#: 0 L FROM TO DIAMETER THICKNESS List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in. MATERIAL
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
AgriCLLltural FROM TO DIAMETER" SLOT SIZE THICKNESS MATERIAL
icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) lerResidential Water Supply(single)
Industrial/Commercialft. ft. In,
Residential Water Supply(shared) IS.GROUT _
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Cr ft. `,—;) f.
Monitoring �J Recove �'�' '°" G f{" 1-1-10
t P rY ft. ft. t{..�4
Injection Well:
Aquifer Recharge OGroundwaterRemediation ft. ft
Barrier 19.SAND/GRAVEL PACK(if applicable) •
Aquifer Storage and Recovery Asa
FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test DStormwaterDrainage ft. ft.
Experimental Technology [Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ()Other(explain under#21 Remarks) FROM ft. Q DESCR6IPTION(color,hardness,son/rock type,Erato sip,etc)
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4.Date Well(s)Completed: '/ d '3 Well ID# R: ft. f)to ' r
Sn.Well Location: Orb ft. y fL r I'i�c��j Se e
+5<"tivYi 4/ d fj�? e j ft- cAr5'•ft-,--., 6 Rs Oe�'
;1�,
Facility/Owner r ame f FacilitylD#(ifapplicable) ft, ft. •'
7-•3•L1 b V> VV2ck C...1b, ? (�C `e.1 f ft. ft. o;s t►.s 1‘...I; V 1 ..... «r
Physical Address, ity,and Zip i ft. ft. i
/, /. . ,,, 21.REMARKS SEF ? 2023
County Parcel Identification No.(PIN) (t1inf.^.il inf=:Sc?? (ir?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ' V°ti �' `
(if well field,one 1atflong is sufficient) 22.Certification:
3 al' 5(°d Wit' s'3. "
`' l °, tl' N it W
6-IS are the well s 12l S.'� f4 lt -L
( ) O ersnaacat ar �ITemporaryS of niEc We1ICan etas lfte
By signing this form,I hereby certify that the well(s)sees(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or - To with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain Me nature of the copy of this record has been provided to the it'd!owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You> Y use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
LJ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: S ( • (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dieirent(example-3@200'and 2@100)
construction to the following:
10.Static water level below top of casing: Lifre (ft.) Division of Water Resource
t.
If water level is above casing,use"+' s,Information Processing Unit,
1617 Mail Service Center,Raleigh,NG 27699-1617
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11.Borehole diameter: C. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
•12.Well construction method �-6$b r R( r 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 I• I I
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 t) method of test: tielay',4.0tre*. 24c.For Water Supply&Infection Wells: In addition to sending the form to
tYP • F'�� u�>S Amount: toe f' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e• 02- completion of well construction to the county health department of the county
where constructed. I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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