GW1-2022-06901_Well Construction - GW1_20220718

i
P in Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only. '
1.Well Contractor Information:
Gary Thompson -14:WATER-ZONES :.. . ,..:y.. --. _.• -:>
.Well Contractor Name FROM TO DESCRIPTION I
4418-A 150 i° 159
ft. ft
NC Well Contractor Certification Number
15.OUTERCASING for:multi-cased*ells`ORLINER a"`livable
Aqua Drill, Inc. FROM TO DIAMETER 1' THICKNESS IMATMIAL
Company Name
16r1NNEWCASINGOR":TUBING `eoth'ermelclosed moo i
2.Well Construction Permit#: t�tQ FROM TO DIAMETER i I TffiCKNEss I MATERIAL
List all applicable well construction permits r e.VIC,County,State,Varlancg eta) ft ft iu.'
3.Well Use(checkwell use): ft. ft in.
,.
Water Supply Well: M SCREEN,",'
FROAJ TO I DIAM)TER I SLOTSIZE THICKNESS MATERIAL
Agricultural I unicipal/Public ft. ft is
Geothermal(Heating/CoolingSupply) ElResid.ntial Water Supply(single) fL % in,
Industrial/Cornmercial ;.-Residential Water Supply(shared) J1S GROUT ,'
Irri ation FROM TO MATERIAL 4 1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: It
Monitoring `-Recov ery ft ft
Injection Well:
& fL
Aquifer Recharge 00moundwater Remediation
19.SAND/GRAVELPACK rfa livable
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL: EMPLACEMENTMETHOD
Aquifer Test OStormwater Drainage ft ft
Experimental Tebhnology 13Subsidence Control ft ft
Geothermal(Closed Loop) [1' Tracer 20:DRILIJNG•L'OG(attach'additi6ridsti6ets;d.neEess
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION ftolor,hardness,sGiVrocktype,grain size,etc.
1' ft. 0 ft.
lJ
4.Date Well(s)Completed: CA -! Well ID# ft ft C'gIi
`
5a.Well Location: ft IC6 ft I.Wff ,`
Facitliity/iOvA erName n Facility
eID#((iifaap�plic-able) O ff• (i ft.
I Joe ,11CJ �l� I ri un, 1( GC• 061 ft. 1 ft MD
Physical Address,City,end Zip ft ft s C
21.RRMARIC
County Parcel Identification No.(FIN) ,,11
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �p�s
(ifwell field,one fat/long is sufficient) 22.Ce 'fication:
l
r 1'FCU
6.Is(are)the well(s) dPermanent or QlTemporary Signature ofC dified Well C ntractor 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 W o with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of[his record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 dwells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this foim within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 2Q100) construction to the following
I'
10.Static water level below top of casing: L10 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing;use"+"
f�• )0- 1617 Mail Service Centeer;Raleigh,NC.27699-1617
11.Borehole diameter: 24b.For Iniection Wells: In addition to
G sending the form to the address in 24a
��tt above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:_-i1C71'tIt i 4"' construction to the following: i
(ie.augey rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: /� 1�-i 1636 Mail Service Cen f r�Raleigh,NC 27699-1636
13a.Yield(gpm) A Method of test: C&Ch 4,`t:�,n�- 24c.For Water Supply&Iniection iWelis In addition to sending the form to
Q the address(es) above, also submit one'copy of this form within 30 days of
13WDisinfection type:WI3` �� 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 Revised 2-22-2016