GW1-2022-03100_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft13(a . 9
4418-A rt. rt. of
(VA Mh
NC Well Contractor Certification Number 15.'OUTER CASING'for multitased'wells OR'LINER' a0"licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in. al Pvt
Company Name K,
1 y f� /�q 16�INNER-.CASINGOR:T:UBING-"-"eothermalrAosed-loo�'�_: _anr,'-�'�"•Q�l`,,..-��;;�._..,.
2.Well Construction Permit#: Ell"©I'tA�.MI-O'WIS% 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 SLOT SIZE THICKNESS MATERIAL +
Agricultural 13 unicipal/Public ft. rL in.;
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single) ft. rt i
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
n Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t 7 I ft-
t K
Monitoring Recovery ft. ' ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
'19,SAND/GRAVEL PAGK4 if;i"'llEbbie�"
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test CIStormwater Drainage ft. ft.
Experimental TechnologySubsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if uecessa '
Geothermal eatin C ciling Return) 00ther a lain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rock type,grain size,etc
10 ft. 90 ft. Ciao
4.Date Weil(s)Completed:,2-17-= Well ID# ft. ft. J
ft.5a.Well Location: 100 IC6 ft. UP ,
HnmoS W�IS10�jC 1 0 ft. it. Slue- C-cyan r
Facility/Owner Name Facility ID#(if applicable) ft. fL
9c.nq I..11/l5�P 511miecQft1 i MC a'7359 rt. rL
Physical Address,City,and Zip ft. ft.
I�Li1l#Ot� �( 21.REMARKS
r
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 0
(if well field,one Iat/long is sufficient) 22.C rditcation:
N n 51' ij.3u N' t'rvf��l��TrviTar ras*fto
6.Is(are)the well(s)6ermanent or Temporary Signa re offertilMd Well Ccliinictor 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 JNo with I5A NCAC 01C.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/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 pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS''
9.Total well depth below land surface: dC16 00 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: 46 (ft.) Division of Water Resources,Information Processing Unit,
If inter level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
n Ai above,also submit one copy of this',form within 30 days of completion of well
12.Well constructionfinethod: mk Nr construction to the following:
(i.e.auger,rotary,cabl4,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) Method of test:&kjn 4 T irle 2dc sFor Water SunDly&Iniect ion 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: N i nR 7001e Amount- ICA67, 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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