GW1-2022-06542_Well Construction - GW1_20220510

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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 ft. DESCRIPTION
ft.
4418-A
ft. fL
NC Well Contractor Certification Number :''45.OUTER CASING'for multi-cased wells OR LINER if a Hcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATFRrst.
ft. `1� ft. in. �' VC
Company Name "16.INNER CASING OR TUBING' edthermal closed400
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
+,17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) &Residential Water Supply(single) ft, ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
_.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. _16*6k
i N� ,
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK"ifs Hcable
Aquifer Storage and Recovery Salinity Battier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 11Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wilfrock type,grain size,etc.
6 ft. X ft
4.Date Well(s)Completed: -14 9-M Well ID# ft' Ci0 It.
ft.0 ft.
Sa.Well Location: 40
// 45
ft' 135 It. IuL a G
Llaflfi �oeS DJ
Facility/Owner Name Facility ID#(if applicable) ft. ft.
McC�'m, �l'.I�ASC,����5 ft. ft. �
Physical Address,City,and Zip ft. ft. d V
Cuy 1 21.REMARKS03
2022 County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ifown'"011 Pry 4
(if well field,one]at/long is sufficient) 22.Certification'
30 90 9.14tt N 'A° W 44,q` wX4 A
6.Is(are)the well(s)cdPermanent or Temporary Signatble ofC Pi6d Well Con for Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or [!�No 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 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
p�pt
9.Total well depth below land surface: 1 a5 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 46 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (b (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�ptl[i't� F1tt A,^ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: h,, 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: ^^11 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) &0 Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
, the address(es) above, also submits one copy of this form within 30 days of
`
13b.Disinfection type: Mm 1001M Amount: IG6L 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