GW1-2022-03101_Well Construction - GW1_20220307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
Gar)/Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 55 k. I�l
4418-A 9,
k. ft
I
NC Well Contractor Certification Number 15.OUTER CASING for multi�ased:welis OR LINER rf a Iicahle
Aqua Drill, Inc. FROM TO DIAMETER` TRICKINESSI MATERIAL.
Company Name © ft. CIO ft / ;' rn. 9"
16.RMER CASING'OR TUBINGIg6thermal dosed 100
2.Well Construction Permit#:���4s!-�j- �utC1�1-�8� 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.
17.
Water Supply Well: FROM SCREENTO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural [3 unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) k, ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
I Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft ,
VIACA
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge []Groundwater Remediation
'19:SAND/GRAYEIPsPACK if a Bcahl'e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft
Experimental Technology Subsidence Control k. ft
Geothermal(Closed Loop) Tracer 20d DRILLING LOG attach additioa`•aisheets'if tiiee"s "
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain siz 'etc.
k. ft
4.Date Well(s)Completed: Well ID# k. ft
5a.Well Location: k. go
ft
k. ft t�1
Facility/Owner Name n Facility ID/#(if applicable) ft. ft.
551S ling 1�MJ/-&�j' nsbnra,ix of/4� ft
� . ft
prrimirm
Physical Address,City,ad Zip ft.' ft
21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification: i 0r
3V 01' eA.91(" N -A° 5G' �O.&692" W J"aet�-
6.Is(are)the wells)&ermanent or E3Temporary Si#.L-.fTertMed Well tracts or ! Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or WNo 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 ofthe 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-I 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: 015 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 40 (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 Iniection Wells: In addition to sending the form to the address in 24a
V�1' p� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y W R.,r construction to the following:
(Le.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) Method of test:Cfk�'Ch !k L a+M. 24c.For Water Supply&Iniect➢ori 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: NTH VO% Amount: Mau- 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