GW1-2021-06261_Well Construction - GW1_20211123

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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
k.
4418-A1017
© ft
k. rL D
NC Well Contractor Certification Number 15.OUTER CASING(formuhf-cased;wells OR:LIIVER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
C) ft. o It. in. cac�A1 e
Company Name ,V Ou
r7 ^ 16.INNER CASING OR TUBING eothermal dosed400
2.Well Construction Permit#: d�rY I d3� 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): k. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) ffRsidential Water Supply(single) ft. ft. in.
Industrial/Commercial [3Residential Water Supply(shared)
's18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 23 ft. ; C
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
39.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control k. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional-sheets'if necessary)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardness soiUroek rain a etc
ft. ft. /(
4.Date Well(s)Completed:_I 13^a I Well ID# ft. tt. 1
5a.Well Location:
5 k. ft.
fL ft.
Cltlukin M&Ae Names 'P�tt��lltUe rt. Lie
Facili /Owner Name Facility ID#(if applicable) IQ F
All I�,ecne dl4 U1 suMei AX b INS k. ft.
Physical AMA,City,and Zip ft. ft. N O V 2 3 20
21.REMARKS
County Parcel Identification No.(PIN) QVVR SECTION
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 11, 013MATION PROCESSING UNI'
(if well field,one lat/long is sufficient) 22.Certification:
36c, Q" lud' N 80° 9, Sg.�" w
6.Is(are)the well(s)C�Permanent or TemporaWNo
Si re of ert red Wd 1 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: Dyes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown 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 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: IZiS 00 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: 40 (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: tD (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�n1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method 1r�6�OCU �,C 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) .:"" Method of test: Chkch TW_ 24c.For Water Supply&Injection 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: NYN %7CP/n Amount: I(A67- 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