GW1-2022-06006_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD(GW 1) For Intemat Use onty: Print Form:. 1
I.Well Contractor Information:
Gary Thompson
14:WATER ZONES.:..:
Well Contractor Name FROM TO DESCRIPTION
4418-A 0 ft. ft
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased well§:OR'LINER if a- licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. t ft G CJ in. Cif i Vc
16.INN ER CASING OR TUBING: eathermaidosed-loo
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
list all applicable well construction permits(Le.UIC,County,State,Variance,eto.) fx ffi in
3.Well Use(check well use): ft. ft.
Flee Supply Well: '.17.SCREEN;:'.s-:;`," -
ultural FROM TO ➢IAMETER SLOT SI7£ THICKNESS MATERIALunicipal/Public ft. ft run.
hermal(Heating/Cooling Supply) 1. Residential Water Supply(single)
ft fttrial/Commercial Residential Water Supply(shared) 18::GROUTt10IIFROM TOMATERIAL EMPLACEMENT METHOD&AMOUNTater Supply Well: Q et. ftt7Llt; Chi S °�Ii d)'tA�Z'
toring Recovery ftn Well:er Recharge E]Groandwater Remediationit iter Storage and Reco 1%SAND/GRAVEL PACK if a"liableY QlSalinityBarrier FROM TO MATERIAL EMPLACEMENTMETROD
er Test OStormwaterDrainage ft. ft
D. Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLINGLOG attach additionaliheets ifneeess
Geothermal(Heating/Cooling Return) 'Mother(explain under#21 Remarks) FROM TO D/EaSCRIPTION color,hardness sui0rock a in stce etc)
. 3-a�>� ft ft Clot
4.Date Well(s)Completed. Well ID# ft. �� ft
i
Sa.Well Location: �0 ft. �3
f1tiAon Jai©! ;le !-f��►t9s 9• ft.. 93 �
FaciliOwner Name Facility ID#(if applicable) qv- ft• ft
ft ft.
G �'CflQ�la/l �alck�t1
Physical Address,C �T �{1�Ica
ity,and Zip ft it. J
t61. UN
71.REMARKS 2�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f
(if well field,one lat/long is sufficient) 7 JA
22.Certification:
4©35° 7r- 5 x �° �1I1 1IB st' �• t
W �� 36.Is(are)thewells)I__.Permanent or oTemporary Signature of erti d ell Co tractor 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 weft: []Yes or EdNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards and that a
Ythis.is a repair,fdl out known well constriction information and erplaln the nature of the copy of this record Iran been provided to the well owner.
repair under 921 remarks section or on the back of this farm
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:
9. list all dep SUBMITTAL INSTRUCTIONS
For Total well depth below land surface:. (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
F multiple wells depths if (example-3@200'and 2@/00) Y
construction to the following.
10.State water level below top of casing;.If water level is above casing,use A) Division of Water Resources,Information Processing Unit,
"+"
11.Borehole diameter: fin,)
1617 Mail Service Center,Raleigh,NC 27699-1617
n � 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auge,rotary,cable,direct push,etc.) constriction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1D Method of test: C4&C!,AMMe- 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this formwithin 30 days of
136.Disinfection type: N��0�d Amount:— i(ae� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofTnviroumental Quali
ty ty-Division of Water Resources Revised 2-22-2016