_Well Construction - GW1_20230327 (74)

I
WELL�C®l�tSTRITCTION RECORD(GWm1) For Internal Use Only: - Prtnt Form
1.Well Contractor Information: 11
Gary ThompsonI I
14.WATER ZONES I 1
Well Contractor Name FROM TO DESCRIPTION
4418-A 32`.ft' 3"a0 ft cry -Z
-7'+-L O
NC Well Conirectorl Certification Number
4 d ft. yet-2..ft c'r4.+c-1 b,
Aqua Drill, Inc. 15.OUTER CASING(for multi-eased wells)OR LINER Of ap licable)
• FROM TO DLAMETER THICKNESS MATERIAL
Company Name 0 ft. I
^ ft I G:a5 in. 5fi A' s,"
-2,\ ip r
``7 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: 11 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pelmits(i.e.UIC,County,State,Variance,eta) ft ft. in.
in-
3.Well Use(check well use): ft. ft.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gi icipal/Public it it in.
Geothermal(Heating/Cooling Supply) ludi'esidentiai Water Supply(single)
Industrial/Commercial R ft. in.
_ I�Residential Water Supply(shared)
Irrigation 10.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&MIOUIhT
Non-Water Supply Well: 0 ft -,2:) ft
Monitoring .Recovery �N C"1
Injection Well: ft. ft.
Aquifer Recharge 'OGroundwater Remediation ft. it.
Aquifer Storage and Recovery Q15alinityBaffier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology QSubsidence Control It.
ft.
Geothermal(Closed Loop) OTracer
20.DRII,LUHG LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) (DOther(explain under#21 Remarks) FROM TO DFSLT2rPTION(color,hardness,soil/rock type Brain size etc.)
7�Z3 3 ft V fL GI N ii
4.Date Well(s)Gompleted:3 Well DV l .ft. S� fr. S h._,-
.�1� S g i l •
Sala Location: �
i � � ¢¢ � ��jj © ft Ql.c- Gres-r'
l Facility/Owner Name ++ /I ^(� C{q FacrlitylD#(if atpplicable) ft. ft.
.1 •' :-�C.Y �."' Jam.-,?.
f. ft.
Address,City,and Zip
. a k ,s 21.REMARKS '' ' L LJ
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: te`y''' "-)'
(if well field,ono 1at/long is sufficient)
2-7 t 'r L Z`it r iv ?ao ` r, 22.Certification:
0 • 1 Y w
•
6.Is are the wellsr - d"Cott 3` L �?i
Is(are) () Permanent orTemporary Signature' o Certified Wd}1 Contractor Date
By signing
(were)constructed in accordce
7.Is this a repair to an existing well: iD,Yes or No with 15A NCAC 02C 0100ecr by 154 NCAC 02C.0200cent&that the well(s)We l Construction Standards and that a
If this is a repair fill out known well construction L formation 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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: <�4/%
a200'and2@100� (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
Formalriplewellslistatldepthsifd�erent(example-3
construction to the following:
10.Static water level below top of casing: 5---6 (ft)
If water level is above casing,use"+" Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: k7 (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12 Well construction method: r-t1 }a t�� (y;r above,also submit one copy of this form within 30 days of completion of well
(Le-anger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: C(a 1-i
// // � 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type:7"i )G� ( j the address(es) above, also submit one I copy of this form within 30 days of
it Amount completion of well construction to the county health department of the county
where constructed.
Foam G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 20I6