GW1-2022-05594_Well Construction - GW1_20220614

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson M
DESCRIPTION
Well Contractor Name t
4418-A tNC Well Contractor Certification Number rmulti-cased wells OR LINER H'a licabAqua Drill, Inc. DIAMMATERIAL
60 t in.
60 4 INC
Company Name r1 { 16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: i;t I I' ZY-CIN _ FROM TO DL4�'�7'ER THICKNESSTERIAL
MA
.a--- - --- ft. ft in.
List all applicable well construction permits(i-e.UIC,(aunty,State,Variance,etc.)
ft. ft. t°•
3.Well Use(check well use):
17.SCREEN
Water Supply Well: PROnI TO DIAMETER SLOT S1ZF, THICKNESS MATERILAL
Agricultural '"R unicipal/Public ft. ft iin.-'Geothermal(Heating/Cooling Supply) (( esidential Water Supply(single) ft ft
IndustriaUCommercial D Residential Water Supply(shared) 18.GROUT
hri atiOII FROMMPAeKbl(e)
MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: b SSMonitoring Recoveryt.Injection Weil: t.Aquifer Recharge oGroundwater Remediation
19.SANCK if a licable 'Aquifer Storage and Recovery Salinity Barrier FROMMATERIAL' EPLACEMENT:METHOD
Aquifer Test QlStormwater Drainage tExperimental Technology OSubsidence Control tGeothermal(Closed Loop) OTracer 20.DRttach additional sheets ifnbeessa_ FROMDESCRIPTION color,hardness,soiUmck rain etc.Geothermal eatin Coolin Retum) ^ Other(ex lain under#21 Remarks) O t
ez
ft. ft. ((�
4.Date Well(s)Completed:�ti � Well ID# 1J.
ft ft .0
5a.Well Location:
g ,` fL
FaciEtyt`wner Name Facility ID#(if applicable)
ft. ... -
Physical Address,City.and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcil field,one latAong is sufficient) 22.Certification:
r sr
6.Is(are)the wells)dPermanent or Temporary
Signature of Cl
ti led Well Co tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7-Is this a repair to an existing well: Yes or E(No with 15A NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a
this is repair,Jill out known well construction information and explain the nature of the copy oflhis record has been provided to the well owner.
If
repair under#21 remarks section or on the back of dtis 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: n(fS`7 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 40 (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: liy Cm•) 24b.For Injection 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
12.Well construction method: 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 27699-1636
13a.Yield(gpm) _ Method of test: (rz �rYnL 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: VjNjj170010 Amount• 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 Reviscd 2-22-2016