GW1-2021-07968_Well Construction - GW1_20211122

in 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 163 ft• 1G5 fL 4 0A (lMe+um_
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING'for multi-cased wells OR LINER if a licatile
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 4
O ft. ,Ll5 ft 26 in. R81 ?VC
''16.INNER CASING OR,TUBING(deothermal'dosed-loo
2.Well Construction Permit#: pal•Qnowsn FROM TO I 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.
Water Supply Well: 17.SCREEN
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 'cipal/Public g, ft, in.
Geothermal(Heating/Cooling Supply) ffRsidential Water Supply(single) ft ft. in:
Industrial/Commercial DResidential Water Supply(shared)
III.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o fL fit ,
Monitoring Recovery ft. ft.
Injection Well: fL ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEE:,PACK:'if,ii"licible
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fit. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soil/mck type,grain size,etc.
Qft. ft.
4.Date Well(s)Completed:II-1(e-01 Well ID# ft. 40
fL
Sa.Well Location: fit 14 fL I
f4 fit. '
C1�r0�;nnt C�4ams ��'�lt.lrl�naak3nt45
Facility/Owner Name -fir Facility ID#(if applicable) ft. %
ft. ft
Ce y�th;des e b"I I�r),1JO&1+� �11 . Q79W -
Physical Address,City,and Zip ft. IL N
fJaWb 21.REAIARKS
County Parcel Identification No.(P" MR. ECT1041
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Il'FQRMATinhl P&n!FCSING UN'
(if well field,one lat/long is sufficient) 22.Certification:
350 47, 15.SS" N " 0 5d -11,0"
6.Is(are)the well(s)dpermanent or Temporary Signature of fertified Well7Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair t0 an existing well: 13Yes o[ �NO with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out!mown 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: nn..�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �J (fit•) 24s. 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: 30 (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: CO (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of thisjform within 30 days of completion of well
12.Well construction method: A."r i106 , construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)�
Division of Water Resources,U Dderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test:LAkh 4,TVV- 24c.For Water Supply&Iniection'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: HY '70% Amount: 1(am completion of well construction to the county health department of the county
wl ere constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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