GW1--04658_Well Construction - GW1_20240809

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 1OS IL Iu ft' clpeA (. 6 s.-„
I p tt. i 41. rt.
NC Well Contractor Certification Number
cr`P:4tEr 9 GpE15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
v ft. Sb ft. (/1Z S I LOP .R Pa,K..
Company Name
' ,t 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 11 Oa. 1 I (> FROM i TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. U/C,County.State.Variance.etc.) ft. ft. in.
I3.Well Use(check well use): ft. fa in,
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Municipal/Public ft. I ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial DRcsidential Water Supply(shared) ,
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b ft. I ft. e
Monitoring DRecovcry ft. ft. �}1t+1�tC1'tpS Rv�r rYx�`
Injection Well: r 11
ft. ft.Aquifer Recharge DG roundwater Remediation Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry 0 Salinity Barrier FROM TO i MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage l ft. ft.
Experimental Technology DSubsidence Control ft. ft. i
Geothermal(Closed Loop) 0Tracer
20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock
Geothermal(Heating/Cooling Return) Other(explain under r#21 Remarks) tape,groin size,etc.)
a ft. i b ft. C lla w
4.Date Well(s)Completed: 7'3t-2.9 Well iD#
O ft.
®y
� R. W..t. ®,p vh p )o,I
5a.Well Location: }5-ft. Q d ft. Gt.p l4c_
KR.►t ic `%kitokt) 3,o ft. aevr ft. Grp iv=lam
F t/acility/Owner Name (� Facility iDH(if applicable) ft. ft. `},,,
324 Gr'A.,3ki a �Jh',S+= , "1 tiir`o_ hlC,Z706` ft.
Physical Address,City,and Zip ft. ft. t� 70?4
DA-%i Y s 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one laulong is sufficient) 22.Certification:
t1- e®(e.111 N W24l 5-5; 343ZtI W
6-
6.Is(are)the well(s)Wermanent or DTemporary signor or Ce all fell Con etas Date
B)'signing this form,I hereby certify that the milks)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or o with/5A NC-IC 02C.0100 or l5A.VCAC 02C 0200 Well Construction Standards and that a
If this is a repair.Jill out known well construction information and explain the nature of/he copy of this record has been provided to the well owner.
repair under R 21 remarks section or on the back 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
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only t GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
C, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: d S (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(tg200'and 204100')
/1f constnretion to the following:
10.Static water level below top of casing: ` b (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
i above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: fokwt�1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I ' Method of test: t, i IN1#4r.rroe,. 24c. For Water Supply & Injection Wells: In addition to sending the form to
6 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: � q Vs"i o% i Amount: to .4 , completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Enslmnmental Quality-Division of Water Resources Res sed 2-22-2016