GW1-2021-07571_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary W. Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
aU ft. u I It.
K
4418-A
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NC Well Contractor Certification Number 1 ft- I ��
5.OUTER CASING%✓(forulti-cased:wells OR LINER(ifa Gcable
Aqua Drill, Inc. FROM m
TO DIAMETER THICKNESS TERrAL
© fL )1125 ft in
Company Name '
������ 16;INNER CASING OR TUBING eothermabdosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATRRIAi.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It. tn•
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
pp Y FROM TO DIAMETER' .SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipal/Public U it. & in.
Geothermal(Heating/Cooling Supply) ffRsidential Water Supply(single) ft. ft. in,
lndustrial/Commercial Residential Water Supply(shared) 18 GROUT .
711rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft ft. } mur '
Monitoring 13Recovery fa &
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.'SANDlGRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage & %
NExperimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) E30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock q1m Min sae,etc
Q ft ft. '
4.Date Well(s)Completed: ' Well ID# © ft. Lki ft. I
5a.Well Location: Q I.
lgo ft
lay4 n knUle t 6(hy. o ft ft ,
Facilit{�Owner Name Facility ID#(if applicable) ft ft i
115W ft. ft.
Physical Address,City,and Zip ft. ft
!ti[7UJQf� 21.REMARKS
County Parcel Identification No.(PIN) 1pmnesling
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �(t�QB SeU'ilOn
(ifwell field,one latAong is sufficient) 22.Certification'
5V r 2" N �QO �4r .�11 W �/ j U -2—i
6.Is(are)the well(s) Permanent or Temporary Signature o~t Cervfied w 11 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 MNo with 15A 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 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: 1205
5 00 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii erent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 00 (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: CA (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
r1 n-` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Ax YClcC}�RO 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) o(V Method of test:Cakk!'YIMp_ 24c.For Water Supply&Infection 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: ��70% Amount: I(O©Z 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