GW1-2021-03922_Well Construction - GW1_20210823

101 Form.
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 IWIL
ft (.`il'j l
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ilcable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
® ft. ` 17 ft in. 1
Company Name
�� 16.INNER CASING OR-TUBING eothermal closed400
2.Well Construction Permit#: J FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. fL in.
3.Well Use(check well use): ft. ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 13 unicipal/Public ft. ft. in.:,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Q ft Je_
Monitoring Recovery — ft ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a Hcable
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. iG
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soii/mck Cain size,etc
0 f ft
4.Date Well(s)Completed: SS-S-o?l We11ID# 120
ft. 'g ft -114
`
5a.Well Location: ft. ft
ft
Factl /IOwn�er Name Facility ID#(if applicable) ft. ft
cam`°ti
�145 �X PLJ q S 5 ft. It. 7 ��
.>..,..,
Physical Address,City,and Zip ft. It. J
1 t„� '21.REMARKS `
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
V, l 4 2011 N C(O° 111 W- 3176
6.Is(are)the well(s)IsIPermanent or Temporary Signature ofCertifi1dWell 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 No with 15A NCAC 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 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-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: 00 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@100) construction to the following:
10.Static water level below top of casing: W (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
rr
11.Borehole diameter: lD (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
n `��' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: .0 i1f}Y 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: 11,,-- _` 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I� Method of test:Ct�ifl� ���e 24e.For Water Supply&Infection Wells: In addition to sending the form to
t,-�` �t�p J r the address(es) above, also submit,one copy of this form within 30 days of
13b.Disinfection type:YI 11 'Iy f 0 Amount: k(DOZ 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