GW1-2021-07960_Well Construction - GW1_20210809

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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
rAJ
4418-A \\� e5\ ft. ft.
NC Well Contractor Certification Number
q `ytio �cG 15:OUTER CASING for mu16 cased wells ORLINER If o licsble
Aqua Drill, Inc. n�O �12,✓ FROM TO "=TER THICKINESS MATERIAL
t i a R. d fy�i ft Z In. SD a 2,jPU
Company Name t NN
�� � d C� 4 ,FROM ft. TO ft. DIAL�TE thermal'cl closed-loop)
S 16 1NNER CASING OR TUBING e
2.Well Construction Permit#: � � R THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Valiance,etc.) In
3.Well Use(check well use): ft. ft in.
Water Supply Well: 177SCREEN ".
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft io
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
hTi ti0II FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. —2c- ft �L
Monitoring , Recovery ft. ft
Injection Well: g, ft.
Aquifer Recharge `Groundwater Remediation
19.-SAND/GRAVEL_PACKx it,"a�`"liceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft
Experimental Technology EISubsidence Control ft ft
Geothermal(Closed Loop) 13Tracer 20.DRILLINGLOG attach jidditionel ibeets if Aecessa , '
Geothermal(Heating/Coolie Return Other(explain under#21 Remarks) FROM TO DESCRIPTION rnloy hardness soiUroek win s' etc
ft C p.
4.Date Well(s)Completed: Well ID# t ft• ft p� '5S(q
5a.Well Location: ��� � � ft tf� ft oft J 1� _ 5bn.I s wt.
f t�
A,KA j , JId1,C5 �� ft. ft �G+fph t
Facility/Owner Name i �Facilility ID#(if applicable) (0 R' 2, R 4,Cltt ii,.t
(,,��,0 51 - [_7t7 Lrg N(_ � Z:Hn e.Y ft. ft
Physical Address,City,and Zip ft. ft
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or Temporary Signature o Certified Well 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 ��o 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 Ito 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: "� '4 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ^ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: "7 (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: (m.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
.Well construction method: t)b'R
��pyy z above,also submit one copy of this form within 30 days of completion of well
(L �1 f 1���
(i.e.auger,rotary,cable,direct push,etc construction to the following:
1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) N Method of test: i M r' 24c.For Water Suvoly&Infection Weilsr 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: Amount: 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