GW1-2002-04689_Well Construction - GW1_20020521

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: C�N1` 0
Ga Thompson r�V 14:WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
�
4418-A I.tiAy 21 Z Zvi;� ��c� itb F .� 3c
a r>-
NC Well Contractor Certification Number {�,1.t��.v'ti �C�vY 15.OUTERtCArSING`for multi-cased wells OR LINER ifs livable
Aqua Drill, Inc. ���° �,sJ�a J FROM TO DIAMETER THICIQVFSS MATERIAL
Company Name (� ft 5- ft fJ t L$-, in. I !DA 1 P U
, -16.INNER CASING OR TUBING geothermal dosed-loop)
2.Well Construction Permit#: 3(.�•G G l FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) & & in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public U ft. fa in.
Geothermal(Heating/Cooling Supply) Ofesidentiall Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
18.-GROUT '
Irti ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT"
Non-Water Supply Well: a ft. --->. Gr GPI S
Monitoring DRecovery & fL
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage & ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness,soiurock type,grain size,etc
ft ft. C/.
4.Date Well(s)Completed: "l Well ID# 31- ft &a ft. a '
5a.Well Location: 66 ft. (.Is ft
R. �a rp l a i
,�� c S ft. ZZ�ft. G 1 W t
+-'r �.S A
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
5 i sk
ft ft.
� l.aot.�sowV��(�- wL ���nZti
Physical Address,City,and Zip ft. ft.
s-6 1<_ess 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.�Certification:
p-S �i,LJ/_141 t N d a 16 t , -7 1 W
6.Is(are)the well(s)&ermanent or Temporary Suture o Certified ell 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: ®Yes or ONO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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: -3t-15— (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3(200'and 2@a 100') construction to the following: i
10.Static water level below top
of casing: b (ft) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+"/ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (a
m.
( ) 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: /��krr� 1 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
13a.Yield(gpm) b'Y Method of test:CeAG '�)t h. 24c. For Water Suunly&Injectifon 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 e typ . Amount: G 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
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