GW1-2021-02309_Well Construction - GW1_20210722

Pril�t 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
4418-A 14 ft- ,5D 6 ft � b b I
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING for malt!cased!wells FLIT LINER d a 6cable
Aqua Drill, Inc. FROM TO DIAMETER RICKINESS MATERIAL
Company Name P
C� 76.INNER CASING OR TUBING(geothermal closed loo
2.Well Construction Permit#�'si I —0 lda:;� -j--2p Z] FROM TO DIAMETER I THICKNESS MATFRML
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 icipat/Public ft. IL in.
Geothermal(Heating/Cooling Supply) WResidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z3 ft t,A Ol. 1.-�
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
49.SAND/GRAVEL=PACK:"ifa' Beable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD.
Aquifer Test [3Stormwater Drainage ft. ft
NExperimental Technology 13Subsidence Control ft ft
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional.sheets If necessary)
Geothermal catin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soil/rackrain six etc
O ft. 1 15 ft 6 F \.
4.Date Well(s)Completed: ](t`Z.l Well ID# b ft- Y b ft 0 n
5a.Well Location: 46 ft. LIZ ft �j r b e�•�
L ee ft ,✓��i ft
Facility/Owner Name I p FacilityID#(if applicable) .. ft. J ft e pw
e_��1'UC ft. ft.
Physical Address,City,and Zip ft. ft i- 144
�1r
21.REMARKS a.
ACX e
CC&ty Parcel Identification No.(PIN) fsYO� �n
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
((iif�well field,one Iat(long is sufficient) t 22.Certification:
sZn t rJ, , t�>4'�N ! (k 6 35 �, 1.7pj dl—{l1 W
6.Is(are)the well(s) Permanent or OTemporary Signature of ertified Well onhsctor 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 1No with 1 SA 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pagers if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: :5—b 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi[jerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 1 b (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter: �o (in.) 24b.For Infection 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: !'6"r�0 pi r 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) (OD {' Method of test: C$L' 24c.For Water Supply&Infection Wells: In addition to sending the form to
1_ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:f� Amount: `�.'b D Z" 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
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