_Well Construction - GW1_20230327 (10)

WELL CONRTRUCTION RECORD dC•W-g In
l For ternal Use Only: —Print Form
I.Well Contractor Information:
Gary Thompson 14.WATER ZONES j
Well Cont-actor Name FROM TO DESCRIPTION
4418-A
NC Well Contractor Certification Number
15 OUTER CASING for mutfi-cased wells OR LiNER(if a livable
Aqua Drill, Inc. FROM TO DWULTER THICIWFSS MATERIAL 17
Companyxame fL Lk(e It (�,2-Yj in.
-y 16.IlITNER CASING ORTQBING cothermal closed-loop)
2.Well Construction Permit#: V�1 D Lk FRO51 TO DIAMETER THICKNESS MATERIAL
List all applicable weit construction permits r e.U1C,Cormty State,Variance,etc.) ft. ft in.
3.Well Use(check well use): ft. 11. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Municipal/Public ft. is
dential Water Supply(single)
Geothermal(HeaSng/Coofing Supply) i
ft it, in.
Industrial/Commercial DResidential Water Supply(shared)
Hoation. 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&A IOUNr
Non-Water Supply Well: ft fttii�
Monitoring ORecovery fL
Injection Well:
Aquicharge DGroundwaterRemediation ft, ft
fer Re
Aquifer Storage and Recovery �SalinityBarrier 19.SAND/GRAVEL PACK rf n livable
FRObf TO MATERIAL EMPLACEMENT1l1ETHOD
Aquifer Test [3Stotntwater Drainage ft &
Experimental Technology 1ISubsidenceControl ft.
Geothermal(Closed Loop) 07fracer
2D.DRILLING LOG attach addition alhe ets s if eeeess
Geothermal(Ilea' Cooling Retu rn) �. Other(explain under#21 Remarks) FROBI TO DESCRIPTION(Color,hardness,soiVmck type,grWn Sl a etc
4.Date Wel(s)Completed: �'"`��"'13 Well ID# ft. ft ,
6�
5a.Well Location: D ft. g, 7
_rpt^jn�rt3. t,tcsfirel- dwe ft --ft
FaciliWOwnerName Facility ID#(ifapplicable) ft ft
Physical Address,City,and Zip ft, •�,
v
ft 4.
21.REHARICS �„ n
County Parcel Identification No.(PIN) I N R2 2023
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ; •;to:'.` 2 n p i'^ic ix:�f U,
(if well field,one lat/long is sufficient) a,ram; iJZ:
22.Certification: ID�'
06
6.Is(are)the well(s)' ermanent or oTemporary *SiCertified Weli Cofactor Date
By signing this form,I hereby ce,r66,that the well(s):vas(were)constructed in accordance
7.Is this a repair to an existing wen: ElYes or 014O with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 pleli Construction Standards and ch Ifthis is a repair,fill out ianown well co struclion h formation and explain the nature ofthe copy ofthis record hash—provided to the well owner. at a
repair under#11 remarks section or an 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 of wells censtr+ction details. You may also attach additional pages ifnecessary.
drilled:
-6`y�r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t1 ✓For (ft) 24a.For All Wells: Submit this form within 30 days mrdnplervellslistall depths ifdiJferent(example-3�a)200•and2QI00� Of Completion of well
construction to the following.
lfi f Static water level below top of casing:vafer level is above caring,Is (ft.) Division of Water Resources e"+`• � ,Information Processing Unit,
il.Borehole diameter.
1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:__�A�m�� n,� above,also submit one copy of this form within 30 days of completion of well
(i.e.auge,rotary,cable,direct push,etc.) construction to the following-
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
/ 1636 NUB Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test:'- I�i i L 24c.For Water Suomi &Intec6on Wells: In addition to sending the form to
13b Disinfection e � � �� o the addresses) above, also submit one copy Of this form within 30 days of
tyP • Amount: %t% /� completion of well construction to the county health department of the county
where constructed.
i l
Form GW-1 North Carolina Department of Eavimnmental Quality.-Division of Water Resources
Q tY Revised 2 22 20I6