GW1-2022-03836_Well Construction - GW1_20220331

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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 ft' i5 ft. 5 okC�c
NC Well Contractor Certification Number ' ft. 9 tL 15 /P
15.'OUTER CASING for multi cased4wells OR'LINER'`if a haibIi'
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL.
Company Name 0 ft. 100 ft. C" Z in. al T V C
16.INNER CASING-OR TUBING eothermal d6sed400
2.Well Construction Permit#: 1S(a5 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. it. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural � unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.,I
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. L ft. lue
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19aSAND/GRAVEL=PACK;iflirpU6able
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft, fL
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) (Tracer 20.DRILLING LOG attach additiooil sheets if necessary),
Geothermal(Heating/Cooling Return) EtOther(explain under#21 Remarks) FROM TO DESCRIP i TION color,hardness,soil/rock rain size,etc.
ft. ft. la 10 w;
4.Date Well(s)Completed: 3-7-Z Well ID# ft. fL
5a.Well Location: ft. tL
�lcTtl�on Mc1�1;1e �14meS 95 rL 1G0 it
Facifity^vner Name Facility ID#(if applicable)
ft. fL '
Physical Ad Ass,City,and Zip fL fLMAR 31 20
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
�p O M r 11 N %0 a74' N-14 W
�----3�LQ 'w
6.Is(are)the well(s) _Permanent or ®ITempo;No
A9--_iiufC
i ed Well Con ctor 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: 13Yes or 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �^1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: n/o (N 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 1@100) construction to the following:
10.Static water level below top of casing: L16 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: i>3 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this fort within 30 days of completion of well
12.Well construction method: uni y A,f, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
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: eV YIPKL 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: N YN '7130/0 Amount: koaL completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016