GW1-2022-04052_Well Construction - GW1_20220422

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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 1 ft. t 32 ft 69M }
NC Well Contractor Certification Number 1,70 ft, IV ft. '� t e
'A5.'OUTER CASING formulti!-cased'wells OR LINER da licable
Aqua Dill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name O 'ft. ft. G-o15 in. C,[YO !1 9C
r' 16.INNER CASING OR TUBING(geothermal closed400
2.Well Construction Permit#: d- �a�,�1-��i- a� ti 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 unicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
fAquifer
ater Supply Well: © ft. t ft. ^t T f C�
oring DRecovery ft. 7 ft.
n Well:
ft. ft.
fer RechargeGroundwater Remediation 19.SAND/GRAVEL PACK if applicable)
er Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test ©IStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ( Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
!� It. .90
ft
4.Date Well(s)Completed: o?g-o�a Well ID# V ft. in1900
ft. t
5a.Well Location: 50 ft. g6 ft
t
r 0 ft. ft.
Vi11f11R) l�5''t^.cIll)
Facility/Owner Name Facility ID#(if applicable) ft. C) fL f
9g'QQ /Del'( oco /}cceS �k� mml't' �'�1..tyC 35� ft. ft l �• t`.• ' . ,
�: :h•
Physical Address,City,and Zip ft. ft.
� I� 1 21.REMARKS
County U Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
o �e3 x '--)•.--2-
6.Is(are)the well(s)IdIPermanent or IOTemporary Signa re of C rt d Well C ntractor Date
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well• nYes or EfNo 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 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: (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 r@200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft.) 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: (a (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
P CWV A.' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4� construction to the following:
(i.e.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 276994636
13a.Yield(gpm) Method of test: (1AC)A 24c.For Water Supply&Injection 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: WVIA 7LIP/0 Amount: /Goz. 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