GW1-2022-06146_Well Construction - GW1_20220623

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Gary Thompson lac WATERZONES
Well Contractor Name FROM TO DESCRIPTION _
4418-A
e. s.
NC Well Contractor Certi&cationNumbec
15.OUTERCASING forrnaltt-cased wells RL-INERflfhovUcable
Aqua Drill,Inc. FROM TO DIANWIER I TE cia-mss MATERIAL
O ft. ft in. I C
ComlwoyName -
r 16.'INNERCASINGOR.TIIBINC ' otherwaldosed-1a6 --
2.Well Construction Permit#: FROM TO DIAMETER TRrCKNM MATERIAL
ListaUapplicableuWlconstructionperadUC.e.UIC,Coum%State,Ymiance,etc.) ft. ft. In.
3.Well Use(check well use): ft f' in.
Water Supply Well:
1� F'ROat TO DIAMETER SLOTS17E TIUMNFSS h m lAlEAL
@J
Agricultural unicipal/Public M it. In.
Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) fL fL is
IndustriaItCommercial DResidwfial Water Supply(shared)
18 GROUT
Ilri atiOn FROM TO MATERIAL EMPLACEMEATMMOD&AMOUNT
Non-Water Supply Well: Q tL f4 r ,' :e
Monitoring —'Recovery rL ft.
Injection Well:
urf-Rec R.
Aq barge �GmundwatcrRcmediation _
A9.SAND/GRAVEL PACK(if a 'licabla
Aquifer Storage and Recovery [3Saliniry Barrier FROM TO MATERIAL EMPLACF31ENl'METHOD
Aquifer Test DStomrwaterDrainage it. fL
Experimental Technology Subsidence Control it. R.
_j Geothermal(ClosedLoop) OTtaocr 20_DRILLING LOG(attachaddrtional sheets ifnefessa )
Geothermni(HcatingICoolin Return Other(explain under#21 Remarks FROM To DESCRIlTION(rorar b.,d.-%mlvmdc ' i �
V IL to
ft [3
4.Dale Well(s)Completed: !9-0 Well ID# n rt. rwlpf
So.Well Location:
10 ft
O.tpkn Mnh:ie 14t/ N- ll iu)SIN'lle 3a fL it.
` r
FaciuobwnerName 1 FacilirylDif(ifapplicable) M IL
Ml .ArL-iLI, �?:OSUilit°I c 923� ft. fL
physical Address, and d Zip ft.
' ft.
1
a�fld iU'r•lt3p'1 -2LREMARRS,. UNI-
county Parcel IdentJcation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t _B°'"k"f`C9.1 iti?;a
(ifwallfield,one lat/longissufficient) lsn`0r�' r,iJ� y "v!aI\II
22.Certification: `t t:i:vni ILa
6.Is(are)the well(s)dPPermanent or OTemporary Sign re ofCe �e Well Can r Date
By signing this form,I hereby certify that the uvell(s)way(were)ewatrurled w accordance
7.Is this a repair to an existing 1vt41: E3 Yes or.d D with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 WeU Conrtructfon Standards and that a
lffhIs is a repair,fill out known well construction information and eplain the nature ofthe eOPy of this record has been provided to the uell aimer_
repair under 921 remar/o section or on the back of thisform 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
domed' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:. (Yea[:] (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdi erent(eranrple-3C3a 200'and 2Q100) construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
lfunter level is above casing use"++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ld (in.) 24b.For injection Well In addition to sending the tom°to the address in 24a
n Clh ,Al abovcy also submit one copy of this form within 30 days of completion of well
It Well construction method: F� ry i' construction to the following:
(Le.angel 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: c�YAP^ 24c.For Water Supply&Injection Wells: In addition to sending the loan to
p the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: I-iH V 0 Amount: 16oz completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Gnvimnmental Quality-Division of Water Resources Revised 2-22 2016
1 of 1 6/23/2022, 12:31 PM