GW1-2021-00515_Well Construction - GW1_20210215

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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 ..�f ft. 3 3a ft. �p�}o r r p"-
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER'if n Gcable
Aqua Drill, Inc. FROM TO DIAMETER Tt�CKNESS MATERIAL
ft. I *-7b ft 16,1S in jr V, aV
Company Name
,16 INNER CASING OR:TUBING geothermaldosW-loo
2.Well Construction Permit#: yd'�3 Q IQ/►y FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): fL ft, in.
Water Supply Well: 17.'SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipaVPublic 0 ft. ft. in.
L Geothermal(Heating/cooling Supply) residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) i8:'GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- 'Zl ft
Monitoring DRecovery fL &
Injection Well: ft. ft.
Aquifer Recharge [Groundwater Remediation n
19.SAND/GRAVEI:%PACK"
Aquifer Storage and Recovery Salinity Barrier ;20i'DRILLING
M TO MATERIAL EMPLACF LENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology [Subsidence Control ft. fL
Geothermal(Closed Loop) [Tracer LOG attach'additional'sheets if necessaGeothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) M TO DESCRIPTION(color,6araness soiuroek a in size eta
b l, ft. e t.­'0 z/P
4.Date Well(s)Completed: Well ID# 1 r ft. 5 ft
5a.Well Location: q 45- ft' -7a ft'
l�)rDr 1�D1YlCS ZD ft )�a15 ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
iZ I(p eu -1XD ��yy C70ft.5P- (d 51, .Go\6,.)Y-, ft. ft-
Physical Address,City,and Zip �,�-Jr�J ft. ft.
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) p 22.Certification:
N 1 I'91 Dl � iVv t-a,S�r�1
6.Is(are)the well(s) rmanent or [Tempo 4 ` Signa ofCe tifed Well C ntractor Date
999 '' S �0�\ By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair,to an existing well•_ ®Yes or 1 t 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
'this is a repair,fill out known well construction information and ex la n the nature,o�fft �`^(� `6f this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
�I T\ `5 JC+fCt 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Rs hav same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
ror multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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: rob, J Al 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) Method of test: C%44' . 24c.For Water Suonly&Injection 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: �b��27 JZ}— Amount: !zz
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