GW1-2021-00031_Well Construction - GW1_20210127

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WELL CONSTRUCTION RECORD(GW-1) For Internal USe Only:
L Well Contractor Information:
Gary.Thompson 14:-WATERZ0NW:.
WcllConuactorNamc FROM TO DESCRnrflON
4418 A i o 1ti L0 ft. Erne-tb r �D t, in
1k &
NC Well Canastatar Cattifiaeeion N=bw
35.OUTER CASING tbir.mtddtased:mlla OR .LINER Iftnble.:
Aqua Drill, Inc. FROM To DL�MEfER THIc1t UM MATERIAL
Company Name ft. I `I -L& I G N I L(in. 14 tGr'k'J �ZiAxr_44
16.2MR.CASING OR TUBING `ebthermal closed=loo -
2-Well Construction Permit#;_����C.0 �/ Z-a FROM TO Dtat11LTM THICKNESS L MATERM
List al/applicable rrell eonstracion permfa(t e.UIC.Cam y.State Variance.at ft. ft in.
3.Well Use(cheelt well use): ft ft. in
Water Supply Weil: 17.'SCREEN
FROM M DIAMETER "SLOTS= MHaaysas .nU1TERiAL
griculttual E3M 1cjpal/Publjc 299 O, 10,
Geothermal(Heating/Cooling Supply) §fQdential Water Supply(single) fL ft
Industrial/Commtmaial [311eudential Water Supply(shared) q8 GROi1T-
71brigalion FROM TO MATEWAL I EMPLACEMEMTAMMOD&AMOUNT
Non-Water Supply Weil:. v fL -Z 3 R a Lr �
_ Monitoring f
Recove fa t.ry
Inlection Well: '
f4 R
Aquifer Recharge QGroundwater Remediatioa
Aquifer Storage and Recovery ((�.. Salim Barrier 19.SANDJGRAVEL PACK IF rteable -
[3 ity FROM TO MA E111PLACEIIMWMMOD
lGeothermal
quifer Test oStomlwater Drainage fL fL
xperimental Technology [2Subsidence Control It: &
eothermal(Closed Loop) [3TMcer 20.11 LOG attach additional sheets if uecessard
(Heating/Coolin Retum) _ Other( lain under#21 Rem FROM PROM TO DESCRIPTIOx corer hnraaer�.soiVroelr .g main dw.atet
6 fA d C
4.Date Well(s)Completed: l Well ID# ft tZ 38
91a.Well Location: Ly 7- 'L 6 fLLO t M i
`S f6 � fG
Facility/OwnerNauto FacilityiD--(ifappikable) Zf< 1-(S M ' t h 1 1"
Z,l 5l f,�r e.,U lA r-CO &W X.�,1,c�cQ SonW14-0 6d
fc ft. F;
Physical Address,City.and Zip G as ft ft
f�,� rv�v>et.,c er L + 21.REMARKS
County Parcel identificavon No.(PiN)
JA
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifivell field,one latilong is suffidem)
/ 22.Certification: ��rl i i .��'!on
1—L`1�Ir!ol�N 1 6 (� UO �6t'a 1, W r.p
6.Is(are)the well(s)135'ermanent or OTemporary Signdw—m ofCeffiflea Well Colatractor Datc
By signing dnts farm.I hereby cert j&that the trdl(s)iros(were)continued in accordance
7.h this a repair to an eAsting well: QYes or O rrilh 15A NCAC 02C.0100 or ISA NCAC 02C.0200 JYdl Construction Standards and that a
ff this is a repair,fill oarknotrn rrdl witm rctlon injormar(on and explain the namre ofthe cqW ofthis recmdhas been provided to the aryl turner.
repair smder 021 remarkssecdon area the backojddsform. ,
23.Site diagram or additional well details:
8.For Gcoprobe/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.OW-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. S (ft) 24s. For All Wells;. Submit this form within 30 da
ys of complexion of well
For nndtiple rills list all deptJtr ijdifferent(example-3Qa 200'and 2QiOD7 construction to the following: "
10.Static water level below top of casing: 1.S (ft) Division of Water Resources,information Processing Unit,
Ijrrorer level is above casing,use"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 i-Borehole diameter. (in.) 24b.For Injecdon Wells: In addition to sending the form to the address in 24a
11 above,also submit one copy of this form within 30 days of completion of well
12.Weil constriction method: r`o t b m V A i r construction to the following: .Y,-
(ie.auger,rotary,cable.direct push,toe)
Division of Water Resources,Underground Injection Control Program, ..`
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
=13a.Yield(gpm) J " Method of test: ` 24c.For Water Siiniv&"Injection Wells: In addition to sending.the form to
L� o n the addresses) above, also submit one copy of this form within 30 days of
13b."Disinfection type:h,\� /i Amount: �2— completion of well-construction to the county health department of the county _
where constructed.
Font GW-1 North Carolina Department of Environmental Quality-Division of Water Resoutas Revised 2 22 2016