GW1-2021-00183_Well Construction - GW1_20211213

PIn 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
ft. 15aft
4418-A ft. rt
Lk) OK Uhdkiil
NC Well Contractor Certification Number 45.OUTER CASING for mulfi cased''we11s ORLINER ifa liable
Aqua Drill, Inc. FROM To DIAMETER TRIcxxEss MATERIAL
ft. 53 ft in. Gi)'Rg PVC,
Name Q
"16. CASING OR'TUB ING(geothermal dosed-loop)�o
2.Well Construction Permit#: n� (�U R THICKNESS MATERAAI
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. It. In.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaL/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft ft
Industrial/Commercial 1IResidential Water Supply(shared)
;18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 494 ft
Monitoring QRecovery ft. ft
Injection Well:
It. it
Aquifer Recharge 13raroundwater Remediation
19::SAND/GRAVEL PACK ifs"liable '' '
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soft/o k e,-min si etc.
Geothermal eatin Coolin Return Other(explain under#21 Remarks
k. ft
aij
4.Date Well(s)Completed:11.4 41 Well ID# R. U fa
5a.Well Location: (� ft• (I ft
1% n %',n� at 4 it ft. �1ueav6cot
Facility/Owner Name `` Facility ID#(if applicable) 5 ft. FL .t
'7121 �1tlA ta:lx•1 V tine-1 VPfYIeQ'S \� Or— Ott 1A ft. ft
Physical Address,City,and Zip ft. ft
In(StD�1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 2021
(if well field,one Iat/long is sufficient) 22.Certification:
1(1
0
41 th 1 10 N �(O6 �/ �i.(4t 1 W
6.Is(are)the well(s) ermanent or [ITemporary Signature Ce ified Wed Contractor Date
��y�1�� 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 di No with ISA NCAC 01C.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-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: 05 (B•) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 200'and 1@100) construction to the following:
10.Static water level below top of casing: 140 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (D (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ADO 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 276994636
f
13a.Yield(gpm) 40 Method of test: tCChkrfllt? 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submitone copy of this form within 30 days of
13b.Disinfection type: 14TH l�O�O Amount: NAOL 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