GW1-2021-05929_Well Construction - GW1_20211025

P_pint 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
ft.
4418-A '
NC Well Contractor Certification Number 0 i It- OR ' n
15.OUTER.CASING.for muld-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS afATERIAI
Q ft. i`1 ft in.
Company Name i tic
//�� �qP �1 w�^ -:16.INNER CASING OR TUBING' eother°mal closed-loop)
2.Well Construction Permit#: Q1-02-wkil'�i-n /j�1L'7 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0 unicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft• ft, in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT1.4h METHOD&AMOUNT
Non-Water Supply Well: © ft--
ft. L.
Monitoring [_ Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
`
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock " e in ' etc.)
U ft. ft
4.Date Well(s)Completed: i0-1k-alt Well ID# ft. ` ft
5a.Well Location: -q ftqq ft.
,
Glut qw(les i tt i`i ft. It-
Facility/Owner
Name Facility ID#(if applicable) �I ft. ft
i n`
Physical Address,City,and Zip ft. IL 1
21.REMARKS
County M Q Parcel Identification No.(PIN) es$1�9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
aI'm3� Secti�o
(if well field,one]at/long is sufficient) 22.Certification:
N ° 33t 35.©�t N' A,-'l ILo2,1-
6.Is(are)the well(s)dermanent or OTemporary sifm6wofC ifiedWell qntractor 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: Oyes or do with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 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 thus 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: 3z (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'and 2@100) construction to the following:
10.Static water level below top of casing: 1`) (ft.) Division of Water Resources,Information Processing Unit,
(water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: cc (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
/� � i1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: -ft f1ti 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
t `
13a.Yield(gpm) 1® Method of test: l c&h-k-NrS%e_ 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:tzt[" '70D1O Amount: 6tM 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 r Revised 2-22-2016