GW1-2021-02233_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ..'�� ft. �rpG.`e�
4418-A
k. ft.
NC Well Contractor Certification Number
15.OUTER CASING for:multi-cased;wells'OR:LINER:ifa `Ucible
Aqua Drill, Inc. FROM To DIAMETER THICIQYESS MATERIAL
ft. (..lei in. Sala.Z� QVZ.
Company Name
16.INNER CASING OR TUBING 6thertnal diised400" '
2.Well Construction Permit#: FROM TO DIAMETER I 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 St7E THICKNESS MATERIAL
Agricultural 13MunicipaL/Public k. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. -a It. Qe�+�ras.�I r 90126
t
Monitoring E3Recovery ft. ft.
Injection Well: k f
Aquifer Recharge E3Groundwater Remediation
19 SAND/GRAVEL:PACK:"if:a-"licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control IL fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'ittaeh:idditlonal sheets if necessa
Geothermal(Heatin Coolin Return Other(explain under#21 Remarks) FROM To DESCRIPTION color,Hardness soil/rock tyM rain etc
L ft. l� ft. G(p ti
4.Date Well(s)Completed:G- a 1 Well ID# k0 k' (per IL b
5a.Well Location: GO fL st' rr!,"Lie
Facility/Owner Name Facility ID#(if applicable) ft. ft. nu
�aSa foSS�/�ek l�v+:l P�AFF P'X fL %
Physical Address,City,and Zip -y7a 7 j n k' It. ` �) 2Q
d
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:
t
6.Is(are)the well(s)(ap/ermanent or 13Temporary Si o Celfified Well Eontractor 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 orCZYN/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 ofthis 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 i 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: 00 24a. For All Wells: Submit this.form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: lQ (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: 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) Z� Method of test: C,0111, Ae14n e- 24c.For Water Supply&In Wells:Wells: In addition to sending the form to
o> the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:144% 0�, Amount: ,(o/�L. 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