GW1-2021-00517_Well Construction - GW1_20210215

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A z3 ft- I z s ft ��� � q1D G p, Y
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING formalti-cased wells OR:LINER if a' licable
FROM TO DIAMETER THICKNESS MATERIAL
Aqua Drill, Inc.
ft. Al ft. ��is in- �/� 4cilLr)
Company Name
�i � MANNER CASING OR TUBING'&othermal closW466
2.Well Construction Permit#: .� �(f wC:k- 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): ft. ft. in.
17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �j unicipal/Public 0 ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.'GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: B
Monitoring Recovery fL ft
Injection Well: ft_. _.._. ft. -.
- Aquifer RechargeGroundwater Rt mediation
19:'SAND/GRAVEL PACK'if a li&ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.':DRILLING LOG attach additional sheets if necessary):
I"Geothennal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiVrock a in size,etc
a ft 1 ft- „()
t`Oa/ C
4.Date Well(s)Completed: — if 'l Well ID# ft ft.
5a.Well Location: ii S ft ft. ,64 +e—
ft.
(G 5-
c rr• G
Facility/Owner Name {l Facility ID#(if/ap_pli-c`able)
ft. ft.
1l't H L Pku rqc- fA, �lJAlyS tc��15 K16,VC` t'L ft. ft.
Physical Address,City,and Zip '�1 „5 ft' ft.
Lek � 21l 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 4�ertification:
N
6.Is(are)the well(s)E35ermanent or Temporary �S�i�Me of Certified Well C ntrdctor Date
�� 1 5 Owning this form,I hereby cert�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or �To 1 with 1 L 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of tI11�+� g his record has been provided to the well owner.
repair under#21 remarks section or on the back of this'form. Cje J 1 P
�`� �+y ggite diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the s5me You may use the back of this page to provide additional well site details or well
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: (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00') 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 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: Cb�-4"4f -n: ✓ 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) `i t' Method of test: 24c.For Water SuuDly&Iniection 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: DX Amount: l� fez.. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016