GW1-2021-03525_Well Construction - GW1_20210607

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, Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
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Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4418-A
ft. ft.
NC Well Contractor Certification Number 45.OUTER CASING for in cased wells OR LINER If
a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. ( ft G,,L-5- in. Sb�LXX f)uc
a 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 1 1 7. 'f�1 Y FROM I To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Counry,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 icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) M ft in:
Industrial/Commercial DResidential Water Supply(shared) i&`GROUT
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. �� faN��� 1
t" � S
Monitoring Recovery ft. ft
Injection Well:
Aquifer Recharge Groundwater Remediation ft ft&MI19 SANDlG1tAVEL PACK°ifs 'livable
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:additionet sheets Ifuecessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiVmck a gmin size,etc.
t) ft. 10 ft C.I a
4.Date Well(s)Completed: 5�-fa-7. Well ID# / D ft' ft. 'r St,'
5a.Well LocatioMn: , I 1-10ft' 7.1 ft 6 .,
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Facility/bwner Name Facility ID#(if applicable) rt. fL a,`p
-?jlb C-1Af' �- 1.. �► 1RcQ r
'a/..e..:�le �2.7eNs' ft. ft
Physical)Address,City,and Zip ft. ft
R" L."Atom 21.RENIARKS
County Parcel Identification No.(PIN)
a4r..,J�.c3b^�CI+af1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
'(if well field,one hit/long is sufficient) 22.Certification:
3 2-7' ��r -bbtt N '775-4' .-J. 1-73�1 W
6.Is(are)the well(s) . ermanent or Temporary Sij&(ure9fCtrrtifiedWeIl Contractor 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 � with 15A NCAC 01C.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 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 I 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: I 00 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'and 2@100 construction to the following:
10.Static water level below top of casing: D (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (e (in-) 24b.For lniection 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: rnJ-U ,r construction to the following:
(Le.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) 1 e>)- Method of test:CJ>6z1.�� G 24c.For Water Supply&lniection Wells: In addition to sending the form to
a the address(es) above, also submit one copy of this form within 30 days of
�13b.Disinfection type: kk-7DhS Amount:J� �i.� 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
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