GW1-2021-07572_Well Construction - GW1_20210903

Pcin, Form %
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A
4 A
�
NC Well Contractor Certification Number r L17
15.OUTER CASING for multi-cased wells ORLINER if a" licable
Aqua Drill, Inc. FROM TO DIAMETER THICMYESS MATERIAL
© it. I JOD it r_ in.
Company Name �a
16:INNER CASING OR TUBING"'(geothermal closed-lob
2.Well Construction Permit#: 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) JoResidential Water Supply(single) ft ft.
Industrial/Commercial 13Residential Water Supply(shared)
18:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. it. t Cho.5 + e
Monitoring Recovery ft. it
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19:SAND/GRAVEL'PACK if a livable
Aquifer Storage and Recovery Salinity Battier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft fL
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 soiVrock a rain size,etc.
- -�f 0 ft. it
Cka
4.Date Weil(s)Completed:`�=�sI-- Well ID# ft. ft 'i1
5a.Well Location: 95 ft• IQ ft ;1`
(1 ►�f� ft. 165 ft
Facility/Owner�Name C \ Facility ID#(if applicable) 4VV It. IL
11(x) RICO i `Xl IlC_ ft. ft 3.
Physical Address,City,a4zip ft. IL sing n1
1 `O 2L REMARKS ItJ,
County Parcel Identification No.(PIN) D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell fiend,,one latllong is sufficient) ``,,o. t 22.Certification:
r rye
6.Is(are)the well(s) Permanent or Temporary Signature ofCerfifiediIVell Cofftractor Date 7l
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: 13Yes or WNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �/. _J SUBMITTAL INSTRUCTIONS
.JV 9.Total well depth below land surface: (B-) 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@1000 construction to the following:
10.Static water level below top of casing: (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: 60 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
C �_ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) '-t Method of test:U1
_c \� 1 4 t01(, 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:N 11'i w/a Amount: I(D,67. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016