GW1-2021-06773_Well Construction - GW1_20210809

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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 -•I-A�,�-o/ ZdGro>'`
ft, ft j
NC Well Contractor Certification Number 15.OUTER CASING for mal_ ed.wells OR,LINER if a" livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ba ft. �Ot�, in. S y1 p r✓VG
Company Name lJ
` 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permitsTi.e.UIC,County,State,Variance,etc.) h fL In.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER, SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. fL in..
Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) g• ft.
Industrial/Commercial 1I11esidential Water Supply(shared)
18.GROUT
7 1ni ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. fL o _ !- �+� b ��•�
Monitoring Recovery ft. ft. fJ��
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19s SAND/GRAVEL PACK`(if applicable)
livable
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test O Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type in size,etc
c� ft. $- ft.
4.Date Well(s)Completed: O Well ID# ft• � ft. (- -�. .;A-21111
) y b
5a.Well Location ' r k' too ft. /r15
LX-3 �1G RDF ycI ' ft.
Facility/Owner Name Facility ID#(ifapplicable) D• ft. +.
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Physical Address,City,and Zip ft
C ] 1
1{t rJ 21.REMARKS
J
-11
County Parcel Identification No.(PIN)
D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 0 22.Ce 'teation•
�A 2a1 06. I L111 N Ste. r w �,&
6.Is(are)the well(s)[2(permanent or f Temporary Signature o ertified WAl 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: MYes 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: D 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of casing: (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
r�A r �' r 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
1
13a.Yield(gpm) �"� Method of test: ��V"L 24c.For Water Supply&Iniection Wells: In addition to sending the form to
11 } the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: {L1 D)5b Amount: 1 L y/'� 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