GW1--04479_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information: _
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION b
Well Contractor Name .),CAS
rt. 300 ft. F far,i ar I &pp
m
4418-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM T'O DIAMETER 'THICKNESS MATERIAL
O ft. t-i s ft. 6 i i 4—in. S DR.-1 P V C
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
e� a LA 0 4' FROM TO DIAMETER ! THICKNESS MATERIAL
2.Well Construction Permit#: d.0 v� ft ft. in.
List all applicable well construction permits(i.e. UIC,County.State,Variance.etc.)
ft. ft. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Agricultural Municipal/Public ft. ft. in— —
Geothermal(Heating/Cooling Supply) DORcsidential Water Supply(single) ft, ft. in
DIndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
IlIrrigation FROM ft. TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C`h as ft.
gana°f+ a PCuC 4 1\.14t {C
0 Monitoring DRecovery ft. ft.
injection Well: ft. ft.
—
AquiferB Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Stormwater Drainageft. ft.
Aquifer Test �
▪Experimental Technology 0Subsidence Control ft. ft.
I
OGeothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soilrock type,grain site,etc.)
▪Geothermal(Heating/Cooling Return i (Other(explain under till Remarks) b ft. "3 ft. Re a e_\„I 1
4.Date Well(s)Completed:1"23-al 4 Well iD# ft. H g ft. g i 1J'Z �r«f n 1 k< 1
t-j5 ft. 36S ft• 6,itie Graniit. -
Sa.Well Location: ft. n.
Kobuk c%och P•. it._L1
Facility ID# a applicable) ft. ft. ` 2024
ty (ifPP ) ,lJ� 4i _1024
`a•,$O SkA c ft. ft.oCd Of , 1(;ett,erSV \\t NC �,1
ft. ft.
Physical Address.City.and Zip r ' —
���`151 1 a 6-1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
—
(if well field.one lat./long is sufficient) 22.Certification:
it �.
1H3.6
Si,T rc of'ern led Wel ontractor Date
6.Is(are)the well(s))`II Permanent or OTemporary
By signing this form. I hereby certif'shut the well(s)woo(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or C4No with iSA NC4C 02C 0/01)or ISA NCAC 02C-0200 Well Construction Standards and that a
If this is is repair.Jill 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 hack of i/nc'.form. 23.Site diagram or additional well details:
You may 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: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 60S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(g200'and 20'4I00'1 construction to the following:
10.Static water level below top of casing: 5 0 (ft.) Division of Water Resources,Information Processing Unit,
if water level is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
//
11.Borehole diameter: b (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
f�
above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: RbN-0.f1 Pit C construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IC) Method of test: C01kC1N"ti gene 24c. For Water Supply& inieclion Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: tA C 1A 7 u°`J ie Amount: 1 b Gib completion of well construction to the county health department of the county
where constntcted.
Form(;W-1
North CarolinaDepartment De aliment of Environmental Quality-Division of Water Resources Revised 2-22 2I)16