GW1-2022-06005_Well Construction - GW1_20220615

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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 I DESCRIPTION
4418-A Q tt. ft. 166 CAR
NC Well Contractor Certification Number rt. ft.
15:OU'I'ER'CASING for mnlfi-cased:wells.ORLINER rf a licible-,
Aqua Drill, Inc. FRObr i0 DIAMETER THICKNESS MATERIAL
O ft 2G ft in. 1
Company Name 3J O`
16.INNER CASING OR TUBING eothermilw6sed400
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(r.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 S1ZE THICKNESS - MATERIAL
Agricultural Q unicipal/Public ft in.
Geothermal(Heating(Cooling Supply) residential Water Supply(single) fttt it in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT _ -
Ifri ation Non-Water Supply Well: FROM TO MATF.RiALEM PLACERTEICT H METOD&AMOUNT
fit fit
Monitoring Recovery fit ft.
Well:
Aquifer Recharge QlGroundwaterRemediation ft. It _
uifer Storage and Recovery .19.SAND/GRAVEL PACK-if a lkc61e
A _
q g � DSalinityBarrier FROM TO MATERIAL EMPLACEMENTMETHOD"
-.'Aquifer Test 0Stormwater Drainage ft fit
Experimental Technology OSubsidence Control 77
fit fit
Geothermal(Closed Loop) EITM= 20.DRILLING LOG'attach additional'sheets if uecessa '.;,,,,RGcothermial.(HeatingdCooling Return) `" Other(explain under 021 Remarks) FROM To DESCRIPTION color,hardness,wiilrocktype in s' etc)
fit /d ft
4.Date Well(s)Completed:kiLLX Well ID# 10 It. ft ,
5a.Well Location: fit I.
'Iro pY1 �Ir4'' fit fit
l i r �f
Facility/Owner Name Facility ID#(if applicable) ft. fL
fit ft
Physical Address, t ddress,City,and Zip f
54 -18 21:REMARKS ;,.;.. ..:
County Parcel Identification No.(PIN)
' Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees:
°eta, w1 i9il 1
(if well field,one lat/long is sufficient) R!4T v ;i" I r r rytkr e�t_ 22.Certification:
2! ' 9I ll 3t N_
1'
W `__`)Ll
6.Is(are)the well(s)dPermanent or OTemporary Signature ofCe 'fled Well Contractor Date a
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: 0Yes or i_.-No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out]Drown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider#21 remarla iecdon 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: 1?05 00 24a.For All Wells: Submit this form within 30 days of completion of well
For rmdtiple we1k list all depths if different(example-3@200'and 2(Qa 100 construction to the following:
10.Static water level below top of casing: 00 (fit) 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. I O (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
(�C2w Air above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: T 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) Inn Method of test: 6tart h 4 T,'Me. 24c.For Water Suimly&Iniection 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: H M 76% Amount: _ IGOf- 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
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