GW1-2022-04032_Well Construction - GW1_20220422

PrinfiForm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Gary Thompson 14:WATERZONES.
Well Contractor Name FROM TO DESCRIPTION
4418-A qd ft. 160 tt. as com
RZ 65 fL o C_Aur
NC Well Contractor Certification Number 15.,OUTEWCASING:formulticased':welts)ORLINERifa licable
Aqua Drill, Inc. FROM TO DIAMETER TIICKNESS MATERIAL
Company Name /\ ft' 50 fL / in. 91 L
eat
SO
•�JQ - ' 16.1NNER CASING TUBING '�(geothermal closed-loo
'Xb/ - -•..- _
2.Well Construction Permit#: 7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) H• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural i unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E31tesidential Water Supply(single) ft. ft. in•
Industrial/Commercial DResidential Water Supply(shared) q8:GROUT '
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
Injection Well: _ ft. fr -
Aquifer Recharge [IGroundwater Remediation
_ �.19.SAND/GRAVEL PACK if a ticatile
Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft ft.
Geothermal(Closed Loop) QlTracer :20.DRILL INGLOG attach additional slieets if necessa
'•> i" FROM TO 'DESCRIPTION color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) rr6iber(explain under421 Remarks)
ft. go ft.
4.Date Well(s)Completed: Well ID# a ft. u tt
5a.Well Location: Q5
ft 50 ft, a +N
Coe net '?1cicofs 56 tL lq5 . SILO- 64 Orin
Facility/Owner Name Facility ID#(if applicable) ft. ft.
JLYL 141M •'I7.iln r ck)i SaO; t ig'70 25 ft. ft
Physical Address,City,and Zip ft. ft.
i:.•21 REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6.Is(are)the well(s)[ (Permanent or OTemporary Signature of a Ified Well C ntmctor Date
By signing this form,I hereby certify that the tivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: n Yes or gNo with 15A NCAC 02C.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 thisform. 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: qq SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use
r"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: l4 (in.) 24b.For Iniection 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
111 k 12.Well construction method: %Ar c construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL'YI WELLS ONLY: // 1636 Mail Service Center,Raleigh,NC 276994636
C
13a.Yield(gpm) � Method of test: .c).4e11 �- T•,1ne 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�p the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �T(l Iy t0 Amount: 1F007- 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