GW1-2021-02293_Well Construction - GW1_20210722

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 &Idta
k. M
NC Well Contractor Certification Number 15.OUTER CASING formulti-cased)wells) K.LINER af im3ficable).
Aqua Drill, Inc. FROM TO DIAMETER TMCKNESS
ft- In. I
0 % 1 46 A I VUC
Company Name
:A INNER CASING OR TUBING heraidA6i6d4 -,-d60)
2.Well Construction Permit#1BL91q1QV Oil &FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL
3.Well Use(check well use): fL ft in.
W. � .:.�
Water Supply Well: 17�.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) L3Residential Water Supply(single) -ft. ft. in.
Industriall'Commercial [3Residential Water Supply(shared)
18.-GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. fL
kftbbAd (NIPS 4- Rttktial
3Monitoring 13Recovery ft. fL V
Injection Well: ft. ft.
19.,SANDIGRAVEUPAGK�(if*
3Aquifer Recharge [3Groundwater Remediation ftllci W�W MI 10_ l b
17
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD,
Aquifer Test [3Stormwater Drainage % fL
Experimental Technology [3Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer
Geothermal(Heating/C Olin Return) C30ther(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil rockrain--size,etc.)
0 ft. Z It. Arti-
4.Date Well(s)Completed: Well ID# ey\fL ft 1
-Z%.Z 36 3011,
-7 . W& r 5a.Well Location: it- ft nm)�
-relmn, 1s tP10 fL ft
Facifity/Owo-Name- Facility ID#(if applicable) ft' ft.
ft. ✓ ft
QQ?5 TS)Ql1WP50VV_ D9 13 C-.,0�-=
Physical Address,City,and Zip It. ft.
21.REMARKS
County Parcel identification No.(PIN) 202-1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ino Unit
(if well field,one lattiong is sufficient) 22.Certificaypn: IrJ0[rr,3tl0n P-Mce,-S
I ti DV)fr,Sel�'L'011
Ig Li
32 l_N W
e Signaturelif Certifiefi Well Contractor DJt
6.Is(are)the wefi(s)dp Permanent or OTemporary
By signing this form,I hereby certify that the well(s)was(were)cons cted in accordance
7.Is this a repair to an existing well: ®Yes or jJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: tt SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. 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@1001 construction to the following:
10.Static water level below top of casing: qC) (fL) 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: (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ks %&AQI above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) (7
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Method of test: 6 & Toni 24c.For Water Supply&Infection. ;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: BTk %0/o Amount: (0 al- completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016