GW1-2022-07007_Well Construction - GW1_20220725

P.rint'For m`..-.
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
. i
Well Contractor Name FROM TO DESCRIPTION
4418-A 70 ft. 71 It 1'{ (ae
ft. ft
NC Well Contractor Certification Number 15..OUTER'CASING for.multi-cased wells OR L' R if a` lica6le-
Aqua Drill, Inc. FROM TO DIAMETER TMCKNESS MATERIAL
in. -• t'i 1 L P1 1
Company Name v �O
�FR -16.INNEWCASING"OR TUBING eothermalAbsed-loop)
2.Well Construction Permit#: {11l9ta'l_Jl.1lR1 FROM To I DIAMETER THICKNESS 5ATERIAL
List all applicable well construction permits(4e.UX,,County,State,Variance,etc.) [t it In.
3.Well Use(check well use): ft ft in.
Water SLi upply Well: 17:SCREEN. ,.
FROM TO DIAMETER SLOTSIZE THICKNESS AATERIAL
Agricultural tmicipal/Public ft. 1t in.
Geothermal(HeatinglCooling Supply) ; (Residential Water Supply(single) fi ft is
PIndustrial/Commercial DResidential Water Supply(shared) ,'18.GROUT'
lirigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
Monitoring ORecovery g. ft Y
Injection Well: I -
ft. ft
Aquifer Recharge 0,Groundwater Remediation
.19.'SANDZGRAVELPACK rfa licable,
Aquifer Storage and Recovery DSalinity Barrier FROM TO, MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft.
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional§heets if necessary)
Geothermal (Heating/Cooling Return) FlOther(explain under 421 Remarks) FROM TO DESCRIP110N color,hardness,soiVruck type raia size,dc
ft An ft d
4.Date Well(s)Completed: Well ID# xR C ft
5a.Well Location: ft 04
Lily laories 0 ft. 05
ft r eo '
Facility/Owner Name Facility ID#(ifapplicable) H• ft y
t���► R e �au� ft ft JUL
Physical Address,City,and Zip ft. ft
21.REMARKS On Procaa'�,.
l�r�»ttk
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattllong is sufficient) 22.Certification: i
6.Is(are)the well(s) Permanent or OTemporary Signature of fled We ontractor Date
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: E]Yes or E-31NO with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this 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 021 remarld section or on the bac/c 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:
rr1� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 da s of con letion of well
For mulaple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following' y p
10.Static water level below top of casing: %{� ft
( ) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CQ (in.) 24b.For Injection Wells: In addition to sending the fort to the address in 24a
/ t Aj� 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) I Method of test: 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit oue copy of this form within 30 days of
13b.Disinfection type: 1-tTR T; /0 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