GW1--04167_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD(GW-1) For internal Use only. — --_._—__..--
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A I6S ft. 110 ft. Pre,1:'ii©t; 1 tr P
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. I 1 OS It. 6 1)1 uk in. SoR`a1 t JC
3 Q� 16.INNER CASING OR TUBING(oeothermal closed-loop)
2.Well Construction Permit#: ae,> © FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C.County.State.Variance etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
AgrCmllural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) CARcsidcntial Water Supply(single)
ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) —
18.GROUT
irrigation FROM TO MATEIII M. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a' ft. gdatrile
Q
Monitoring 0Recovery rt. 44u� }�yr�.�C
Injection Well:
Aft.Rechargeft. ft.
q 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Other,explain under#21 Remarks) FROM TO DESCRIPTION(cobs,hardness soil r«Q type grain size.etc.)Geothermal I Heating/Cooling Return)
d ft. 1 ft. RecL-Giay
4.Date Well(s)Completed:1-1a-at4 Well 1D# 1 ft, too ft- Sc t(4 ROO<
5a.Well Location: 100 ft. 1 O S ft. gw f
unite
&�
f
ie&0 SA.tA,:i oNi , 105 ft- 3as ft- e i+le 67 r a n i 3rC
Facility/Owner Name Facility ID#(if applicable) ft. ft. {,..
TV BD Soh C9r1'Jti n 9•A ti itr�5\on Salem NC a?1 ft.
(„.'•U �.�
Physical Address.City,and Zip ft. ft.
rorsy ki. 6W3'-i'-5'`1-8511 -21.REMARKS _ I, t
County Parcel Identification No.(PIN) ,� Jr*.,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ ~S(?t:'t•-T
(if well field,one lat/long is sufficient) 22.Certification:
3 'la' SboI,,
6` N 800 N. 3.S w
6.Is(are)the well(s)53Permanent or Temporary Si o c cd Well onttactor Date
BI•signing this frrnn.I hereby certlft,that the weeks)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or DONo with ISA NCAC 02C 0100 or 1SA NCAC 02C 0200 Well Construction Standards and that a
If this es a repair,fill out known well construction information and explain the nature of the cope Piths record has been provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
R.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL LNSTRUCTIONS
9.Total well depth below land surface: 7 (ft.) 24a. For All Wells: Submit :his form within 30 days of completion of we..,
ll
For multiple wells list all depths if different(example-3(m200'and 20y/OIY)
construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
4.muter level is above casing,use"+//•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 9 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
ii above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: O`tO Cl Ii\Ur construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,L nderground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test:CA1kIe 4"tin e, 24c.For Water Supply&Injection Wells: In addition to sending the form to
O the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I •T(M'i Oo Amount: 16 e L completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016