GW1-2022-03099_Well Construction - GW1_20220307

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Prin#Form
WELL CONSTRUCTION RECORD(GW-1) I For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A 0 ft. all
NC Well Contractor Certification Number 10?5.R ft' 75 ft.
15.OUTER CASING for multi-cased,wells ORLINER;if a licable r
Aqua Drill, Inc. FROM TO DIAMETER MCKNESS MATERIAL.
Company Name n 1&INNER CASINNGG OR'TUBING iithermsil losed4660)` ---i.
2.Well Construction Permit#: a i.Q`,((�N -e` 13a 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.
Water Supply Well: .17.:SCREEN.FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
'Agricultural P"unicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) L�'�j,Residential Water Supply(single) ft. ft
Industrial/Commercial E311esidential Water Supply(shared)
18.GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 011.
I It i
Monitoring DRecovery ft. ft
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
I9 SAND/GRAVELPACK'if:a Heabk)-, tc�
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sh6 ts'itnecessa
Geothermal (Heating/Cooling Return) :Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,milfmck type,gnin size,etc.
ft. ft CIa
4.Date Well(s)Completed: 69-�7f C/-Qd Well ID# ft' O ft
5a.Well Location: o ft. 9 ft ,l
t.J;Q&oc N©ne-S ft. 00 ft 6
Facility/Owner Name Facility ID#(if applicable) 100 ft. ft ;
QGC& L.uns{otr)T afiwi Betl AJC 0259 ft. ft
Physical Address,City,and Zip ft. f e
(111; � Ir,I 33 Zl RE11tARK5 O .
County Parcel Identification No.(PIN) MAR DU
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �p� u
(if well field,one tat/long is sufficient) 22.Certification: NO
L P',1ti+E��l U�
:4(0° it, n.'I It N 99° 5j' 11 Y,
6.Is(are)the well(s)CdPermanent or 13Tempo;?No
Signature of CIrm
fie Well Con ctor Date
By signing thi I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: �YeS or with ISA 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 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 rsite 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: nn SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: d06 (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@100) construction to the following:
10.Static water level below top of casing: 40 (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: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n ' A; above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: � li c construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Tf
Division of Water Resources,!Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: f t 1636 Mail Service Center,Raleigh,NC 27699-1636
13a'.Yield(gpm) Method of test: CnttCY1 ':MP 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: 141A:Jn0/0 Amount: l(CItNL completion of well construction to,the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016