GW1-2022-04892_Well Construction - GW1_20220525

Prlrif form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
I.Well Contractor Information:
Gary Thompson 14.WATER.ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A ft it CqL
ft• ft
NC Well Contractor Certification Number
15.OUTER CASING for'muld-case`dwc:koRLINER tfa luable
Aqua Drill, Ift. FROM TO DIAMETER THICKNESS MATERIAL
ft
Company Name 0 ft. in 1 (—
. t"%16:=TNNER CASING ORTUBIN(G
IA _('eothermnhdosed-too
2.Well Construction Permit#: 7 FROM TO DIAMETER THICKNESS HATERIAI.
List all applicable well construction pow is(i.e.UIC,County,Slate,Pariance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
d E) unicipal/Public ft. {t in.
Geothermal(Heating/Cooling Supply) j' Residential Water Supply(single)
ft. ft. in.
Industrial/Commercial Dkesidential Water Supply(shared)
`18.-GROUT
nirr FROM TO
Non-Water
MATERIAL EMPLACEMENT METHOD&AMOUNT
Water Supply Well: � ft. ft ' r
Monitoring QRecovery ft ft. u
Injection Well:
Aquifer Recharge ft ft.
' q �GroundwaterRemediation
19:SANDIG RAVEL;PACK
_ Aquifer Storage and Recovery Q Salinity Barrier FROM TO if alicabl%
MATERIAL ENIPI ACEMENTMETHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology DSubsidence Control ft. ft
Geothermal(Closed Loop) [-'Tracer 20.DRILLING LOG attach additional-slieets;if.neeess
Gcothetmal(11catin Cooling Return) M, Other(explain under#21 Remarks) FROM TOny���, DESCRIPTION color,hardness.sankrock e,,min size;etc)
l+
nn ft �Cly ft
4.Date Well(s)Completed: 4' oC Well ID# go ft ft
� t
5aa..Well Location: C2, ftIn
it t
�� 'LIF8tY1 iP�S!l f O fL n ft a
Faaeffity/Owner Named Facility lD#(if apphcable) ft. ft.
-CYAtE I�t `F�r�. SpQlrf.4r� �� ft ft.
Phys Addres,City,and Zip ft ft
iFl['�S 21.REMARKS t��
County Parcel Identification No.(PIN)
s yes yam.-�.
Sb:Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wen field,one lattlong is sufficient) 22.Certification:
6.Is(are)the well(s) Permanent or Q Temporary St re ed Well C tractor x'�f'lir` y l
By signing this form,1 hereby certify that the wefl(s)was(xere)constructed m accoYdauce 7.Is this a repair to an existing well: ayes or do 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 of this record has been provided to the well owner.
repair under#21 remarks section or on the backof this form.
23.Site diagram or additional well details:
S.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:- r �5 (ft) 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@100D
construction to the following:
10.Static water level below top of casing: �I (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �Q (m.} 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:. As above,also submit one copy of this foim within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following:
i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
q 1636 Mail Service Centei,Raleigh,NC 276994636
13a.Yield(gpm) 7 Method of test: h .�,v�,7 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:_� 1 yst H �QL�6 Amount: ��l=y¢ completion Of well construction to the county health department of the county
where constructed. _
Form GW-1 North Carolina Department oflinvironmentail Qual
ity ty-Division of Water Resources Revised 2-22-2016