GW1-2021-05940_Well Construction - GW1_20211025

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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
--1 in c 4418-A 161 ft. I OIA it. -4g uco&o
ft' fL ( M
NC Well Contractor Certification Number ILIA I 11AB I W AR eAxt)
A!i.OUTER CASING formulti-cased]ff'efls) LINER;falo?cable)DIAMETER
Aqua Drill, Inc. FROM TO DIAMETER FTM SS MATERML
ft. I ( in.
Company Name go
16.INNER CASING OR TUBING t6othertamil dosed400i))
2.Well Construction Permit#: t OVM-inti 51n 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. & in.
Water Supply Well: -17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERMATERIALAgricultural imicipal/Public ft in.
Geothermal(Heating/Cooling Supply) RResidential Water Supply(single) ft. fL in
Industrial/Commercial []Residential Water Supply(shared) '.48.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' IL Ceme-rA lar Ah
3Monitoring E3Recovery ft. ft.
Injection Well: ft. ft.
3Aquifer Recharge [3Groundwater Remediation 19.SAND/GRAVEU K PAC (ifs pplicable);
r 11
I-
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERUL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage k. %
Experimental Technology 13Subsidence Control
%
Geothermal(Closed Loop) ®(Tracer 20.DRILLING LOG(afta hadditiorialsheetsifneressary).,
Geothermal(HeatingCooling Return) E3Other(explain under#21 Remarks) FROM TO DESCRtFT1ON(color,hardness,sofllmck type,grain size,etc.)
0 ft. & i
4.Date Well(s)Completed: 10-I3-Q1 Well EI)# ft' 40 ft. I
5a.Well Location: Q0 fL ft. J4 safAl
U. &Ar Wnft5 90 ft- Due &Dzk
Facility/Owner Name Facility D:)#(if applicable) 90 ft. /(0-5 `L 21L&-
CA5i Jt merS ram IM, "Aasmy k1r-z313 ft. ft. 1 9-
Physical Addrc,4,City,and Zip ft. ft.
21.RENIARKS.
fit^n
&WC15CA
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
350 54' t15,611 N VA0 4c: 0-d' N
6.Is(are)the wefl(s)dpermanent or [3Temporary Signa&O of C r Md'Wer-ontractor 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: [3Yes or dN0 with 15ANCACO2C.0100or15ANCACO2C.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:— R05 —(fL) 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 D construction to the following:
10.Static water level below to 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: G
(in.) 24b.For Iniection 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: "LAC al 9,w
(i.e.auger,rotary,cable,direct push,etc.) d' construction to the following:
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: T,mr 24c.For Water Supply&ln*ecdo[n 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: i4TH'7CO/a Amount: 1(06-1 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