GW1-2021-00014_Well Construction - GW1_20211122

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Connector Name FROM TO DESCRIPTION
4418-A 50 61 rL GcPt
ft. Q fL F
NC Well Contractor Certification Number 15.'OUTER CASING for it sed:wells OR LINER'rfa licable
Aqua Drill, Inc. FROM TO DIAMETER FTHICKNESS MATERIAL
R. 7 tL Cr in. I)VC
Company Name
_ n 16 INNER CASING.OW ING, eothermal dosedaoo
2.Well Construction Permit#: Jew )4aa-ASI C fen-kM) 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural unicipal/Public , fL in;
Geothermal(Heating/Cooling Supply) r ft.
Water Supply(single) ft. R in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 30 fL oni�t° Ibur Chi s4 N
Monitoring Recovery ft. ft
Injection Well: ft. rt.
Aquifer Recharge ®IGroundwater Remediation
SAND/GRAYELPACK;ifa"licsble . '
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20i DRILLING LOG(attach additional sheets it necessa
Geothermal (Heating/Cooling Return) Other(e lain under#21 Remarks FROM TO DESCRIPTION(color,hardness,willreek rain etc
fL ft
4.Date Well(s)Completed: IP- .�I Well ID# a ft. fL Sul1 A
Iri
Sa.Well Location: o!O f ft Co
(t P,fle, (U5kMS C ,f lift 9117 ft. 166 fL Slur- GMCW NOV 2 2 2021
Facility/Owner Name Facility ID#(if applicable) ft. fL
SIShij ft. % I MATnm wnresqiNiG i i (-
Ph
y
sical Addres ity,and Zi It. fL
V�cSon 21 REMARKS
County Parcel Identification No.(PIN) qY" L net'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3GO 171 31.9tr N 79° 3' L43.3/t 11,
w
6.Is(are)the weil(s) Permanent or ®(Temporary Signature o ertified Wet 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: 13Yes or UNo with ISA NCAC 02C.0100 or ISA 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-I 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: '615 (t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 r@200'and 2Q100D construction to the following:
10.Static water level below top of casing: jdQ (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: L6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
A`� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: H 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) elll Method of test: urn 4' T'i(h� 24c For Water SuDDIv&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: NTH '7a010 Amount: 1&AZ 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