GW1-2021-05941_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
Gary Thompson 14.WATER-ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A 1.10 ft. IOU ft
ft. ft.
NC Well Contractor Certification Number ;35 OUTER:CASING for multi-casedwells OR LIIdER'da licable`-
Aqua Drill, Inc. FROM TO DIAMETER TLDCIQYESS I MATERIAL
Company Name
Q ft. t7 ft in.
16 INNER CASING OR TUBING eothermaltclosed-166
2.Well Construction Permit#: .9 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 JaMunicipaMblic ft. ft. in.
3,1 Geothermal(Heating/Cooling Supply) ffRsidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
Irrt ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © B ft.
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19 SAND/GRAVEL.PAGK'if.ib)li able
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20;DRILLING LOG ittach`additioria[sheets if necessa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardy wit/rmk ere.rain size )
ft. It.
4.Date Well(s)Completed: Well ID# ft. ft ,
5a.Well Location: ft. 70 ft o,
ft '7 ft
Aue
/t1
Facility/Ow�nerNa�me r M � Facility ID#(if applicable) � ft- lim
ft ,
�puA�/M1tS�CCS 1;i C�E��504 cfff8m. IJC X_;8 ft. fL
Physical Addregs,City,and Zip "t ft. ft Q rt
�n9
�2ui1�'txc? L.c Col 21:REnfnxxs t
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:
151054, 45.51t N ;90 4C U91" w
6.Is(are)the weil(s) Permanent or Temporary Signa re of ed W Contractor Dace
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or JNo with I5A 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 I 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: 1%C J (ft-) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2/0'0'and 2@100) construction to the following:
10.Static water level below top of casing: (fL) 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 infection 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: I&W K'sconstruction to the following:
(i.e.auger,rotary,cable,direct push,etc.) dT
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: // ���� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �d Method of test:C.aKh rrttle 24c.For Water Suoaly&Iniectitin Wells: In addition to sending the form to
NTH
address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: NTH Amount: [GOL 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