GW1-2021-03053_Well Construction - GW1_20210620

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name YY^
4418-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a t 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
ft. <T ft. G,1,T in. 1 5 O K�L 1 I p v c-
-� 16.INNER CASING OR TUBING thermal closed-1
2.Well Construction Permit#: 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Countv,State, Variance,etc.) ft. ft
3.Well Use(check well use): ft. tt. in•
Water Supply Well: 17.FROM SCREENTO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaUNblic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) 19.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: -6 ft. Zs- tt. _ �s'r C
Monitoring 13 Recovery ft. fL
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if eecessa
FROM TO DESCRIPTION(rnbr,hardness,wiVrmk type,grain size,etc.
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
ft. ft ( N
4.Date Well(s)Completed:�'Ll 1 Well ID# ft. ft.
5a.Well Location: S D ft.
. t c f. D ft CCA.)AlJ1Jl �C
Facility/46wner Name Facility ID#(if applicable) ft. ft.
/�
ft. tL
rS A4t" , c_s h>rQ5 Lpt'P_.. C e r'0 AiN&i) Lk
Physical Address,City,and Zip 1 ,� ft. ft. xl 2
27� � � I`1
S-h ke;s 21.REMARKS rn li
County Parcel Identification No.(PIN) `3t Ott
V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N ��rs%SAD l r f7� S W _r,✓� ➢Zri� to _<
6.Is(are)the well(s)12(Permanent or OTemporary Si6dnaTure 4Ceriified Wellitontractor Date
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 JffNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Irthis is a repair,fill out known well construction information and explain the nature of 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:
8.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 1 GW-I is needed. Indicate TOTAL NUMBER ofwelis construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
' /
9.Total well depth below land surface: `�05- (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@200'anfd�2@1001 construction to the following:
10.Static water level below top of casing: Sb (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 Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method above,also submit one copy of this form within 30 days of completion of well
CD C 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: CP k21.1�'iMC- 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
13b.Disinfection type: h+k'1 D% Amount: ,G 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