GW1-2021-02035_Well Construction - GW1_20210620

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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
I ft' l sa ft. S{C- I"
4418-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
a ft. !iS ft. C..2� in.
Company Name 16.INNER CASING OR TUBING eothermal dosed400
2.Well Construction Permit S3 '�-'Z'b 2 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 [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' "�S iL r(�c' 3 �c/
Monitoring ORecovery ft. ft.
Injection Well: -
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATEPIA EMPLACEMENT METHOD
Aquifer Test ❑IStormwater Drainage
Experimental Technology ❑I Subsidence Control
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,wil/mck t rain size,etc.
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) 4) ft. Za ft. C t
40
4.Date Well(s)Completed: w`t('Z( Well ID# 2.b ft. : _ ft rt•
ft, ft.
5a.Well Location: i!p
rt �tp
. ft,
�s .
Facility/Owner Name Facility ID#(if applicable) Z ft. G r bra
�t ft. ft.
Physical Address,City,and Zip ft. fL O \l
21.REMARKS n
n;
Countl Parcel Identification No.(PIN) O�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) I 22.Certification: l
,7Q0ff6_ 53'�o�1�trN �c�A r� Zl, 77� -! �1 -2-
6.Is(are)the well(s)OPermanent or ❑ITemporary Signature 9TCertified 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 Bio 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/DFT 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: �ZS (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@I00') construction to the following:
10.Static water level below top of casing: �o (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caving,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C, (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: �i5'Fid / /0 :! 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) I .5 Method of test: <A• ,4 r'Me_ 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: O fl, Amount: 1 �� 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