GW1--04805_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 "
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION 1
4418-A 66Oft. cc! ft. z i Miyrriatim)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ag llcable) -
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. (OrD ft tf"•z in. eivt gi y�VC y 9�Ne��( 16.INNER CASING OR TUBING(geothermal closed-loop) 'f
2.Well Construction Permit#: 'AWL r1U41Y Qloi FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consovcuan 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
FROM TO DIAMETER SLOT SIZE THICKNESS : MATERIAL
Agricultural Dt
unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in7
Industrial/Commercial 0Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.AMOUNT
Non-Water Supply Well: d ft. ,;20 R. ,telllli+L' }?bur �1ij °t 1ty/fl�$t
Monitoring Recovery R. ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) D Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION Icolor,hardness soitirork isp e,gain size,etc.)
!� 0 ft. 40 ft. ciao
4.Date Well(s)Completed: tS'1`;Ai Well ID# + Oft. 96 ft. .
sandz S"+
5a.Well Location: 95 ft. POO ft. � (
Duren 8,ahl IOC ft. .5 ft. %-kle- _^.gym ---
Facility/Owner Name Facility ID#(if applicable) ft. ft. �, rlT
, -N.... ',.'L. / L t .
y ft. ft.
'f ,P i.It�IP lr`t.1;t I i 91 4 hccy1 :r1 MC_�)0'41
Physical Address.Ca7'�and Zip ft. ft. AU fa I L. 20?4
et
t1(o7-00,,2 '-55P 21.REMARKS
r 5
it '
County Parcel Identification No.(PIN) L.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latilong is sufficient) 22.Certification:
Ace') 25' `ni' •(.7°" N VO° a")' 1794 w
6.Is(are)the well(s)dPermanent or Temporary Sigr attire o -eniticd Well Co ctor Date
By signing this ftrio, 1 hereby certify that the well(s) was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or leiNlo with l5A NCAC 02C.0100 or/5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill out known well construction information and explain the nature,if the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
R.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 I 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: 5.25 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii different(example-3(0200'and 24'4100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water love/is above casing,use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this; form within 30 days of completion of well
12.Well construction method: Waal A1^ construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) "r�-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: CG,1/41141,111Z. 24c.For Water Supply& Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
WY, '
13b.Disinfection type: Il-1 (O Amount: 14eL completion of well construction to the county health department of the county
where constructed.
Form GW-I North Camlina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016