GW1-2021-04685_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
I.Well Contractor Information:
Gary.Thompson 14.WATERZONES
Well Contractor Name !.t t FROM TO: - DUCWMN
4418-A '
���aY 21 2021 & ft.
�iC Won Contractor Certification NumLe rytNGrC''^l;y, �Il#� IS OUTER SING forIDdtt wells OR LINER limbic
Aqua DHII, Inc. . !t-�{�� �� n Tfut:�' aalpA IAL
R ft t?j hr S /s.L� WCi
Company Name-
r / ) 16 2NNER G OR-TUBING therrad dosed-lob
2.Well Construction Permit#:C e4jl�l0.lo�®;y FROM To Dwnsrftt TWINM MATER L
List all appiieable r+eil construction pemdts r e UIC,Comrty.&me,rrarlanee,eta) % % in.
3.Well Use(check well use): R tt.1 in.
Water3upply Well: 1?'SCREEN FROM TO I)L ML4M SLOTS= I MHCHMS I MATEUAL
Agricultural & In.
Geothermal(Heating/Cooling Supply) Wcsidential Water Supply(single) g R in
Industrial/Commercial (31tesidential Water Supply(shared) ,
�18.GROUT . - :. ..
Irri lion FROM TO AL►TERiAL IIriPIJ10E64Nf MMOD&MTOUNT
Non-Water Supply Well:. I, ft /O.S 0�� d-
_.Monitoring Recovery fa ft
„6
Injection.Well; &
Aquifer RechargeGroundwater Remediation
39 SAND/GRAVEL PACE rf a icable " " ''
Aquifer Storage and Recovery Salinity Barrier FROM TO 51ATERrAL FfiiPLACEMtSrrNEMOD
Aquifer Test [3Stormwater Drainage & &
Experimental Technology Subsidence Control ft. &
Geothermal(Closed Loop) DTmcer 20.DRILLING LOG attach additional sheets if neassary '
FROM TO DESCRiPIION color hmdnas.saahork eta
Geothermal(Heating/Cooling Rettun) _ Other(explain under 921 Remarks)
4.Date Well(s)Completed: �0 Well ID# 41 ft f
5a.Well Location:
Facility/Owner Name Facility M-1(ifapplicable)
Physical Address,City.and tip ft ft
21.REMARKS
County Paraal identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/secoads or decimal degrees:
(ifwell field,one Wang is sufficient) 22.Cerdf-cation:
6.Is(am)the wells) rmaaeut or Temporary Signature of Certified Well Contractor Datd
By signing this form,I hereby rxr 6 that;die rreU(s)iros(were)constructed in aerordance
7.h this a repair to an Witting well: DYes or QNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 iVdl Construction Standards and that a
if dds is a repair,fill am kaoirn well construcilon information and explain the nature of the ropy ofthis recordhas been provided to the well owner.
repair wider421 twazeksseadonoron the back afthisfonn
23.Site diagram or additional mil details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional%veil site details or well
construction,only I.OW-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: (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple urlis list all depths if different(erample-3Qa Z0000'and 2@1001 construction to the following',
1Q Static wales level below top of casing: 7 (ft) Division of Water Resources,Information Processing Unit,
If inter level is above casing,use"+" 1617 Mall Service Center,"Raleigh,NC 276994617
11.Borehole diameter- 610AC (in-) 24b.For Infection Weill: In addition to sending the form to the address in 24a
t, above,also submit one copy of this form within 30 days of completion of well
12.Well constriction method: construction to the following
(M anger,rotary,cable,direct push etc) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cenp 1ter',Raleigh,NC 27699-1636
-13a.Yield(gpm)_ _ Method of test`ft*eA�4 24c.For Water Suonly&Iniection`Wells: In addition to sending the form to
- �d�� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70�DOl��Amotmt; 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 grater Resources ' Revised 2 22 2016
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