GW1-2023-02666_Well Construction - GW1_20230411

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: —-
I.Well Contractor Information:
i
Gary Thompson 14,wATERZOM
Well Contractor Name _ - _ _ ., FROM TO DESCRH'1'fON
4418-A .T it
NC Well Contractor CertificationNumber t dlt7 ft' 1 jj`. ft. qc�a r SD c9r-
A P R I 12023 IS.OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM To I DIAMETER I THICKNESS MATERIAL
Company Name fr. �� fr. fe.�5 in• 5D�'a t uc
iSii�r�t7.i,.=i1 rti"��:/::�i,;.J ;.. �..
16.INNER CASING OR TUBING eothcrmal closed loo
2.Well Construction Permit#: U •` I'•Y.� FROM To DIAMETER TfficKNESS MATERIAL.
List all applicable well construction permits(Ea UIC County,State Variance,eta) ft. ft in
3.Well Use(check well use): ft. ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural DMunicipal/Public & fr.
`Geothermal(Heating/Cooling Supply) idential Water Supply(single)
ft ft in
Industrial/Commercial []Residential Water Supply(shared)
18.GROUT
n- ate 7SANDIGRAVE11.
To 1ATERUL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 30Monitoring ,�Recovery InjectionWe➢:
A utfecRec ftq �e GroundwaterRemediationAquifer Storage and Recovery Salini Barrier . PACK ifa licahte
ry FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainagefr. ft
Experimental Technology oSubsidence Control ft it
RGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) Mother(explain under#21 Remarks) FROM To DESCRIPTION(color hardness,sallfrock rola sirC erc..
6 ft � ft `
4.Date Well(s)Completed: !�' �7 wen IID# a Ft
ft.
5a Well Location: 11 qq � r -sty ft .7 t3
ft
a Sm J� t�Clre.,•l C.
Facility/(?wnerName Facility EDP(ifappliwble) it ft s
(�(z 1 b�lt7 r�it1t i Ju la li' 1�U:1e ivy Z d t7 ft. ft
Physical Address,City,and Zip ft. %
es 21.REMARKS
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Twell field,one Wong is sufficient)
22.Certification: �
3r✓ is i�. r-���`� lY �d d� 3v��s��
6.Is(aro)the wcn(s) ermanent or Temporary wgukure o UiEfied Well Obnuactor Date j
�� By s4gntng this form,I hereby certify that the ivell(s)'vas(were)constructed in accordance {I
7.Is this a repair to an existing wen: tD,Yes or E314o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knaunr'veil construction information and explain the nature ofMe copy ofthes record has been provided to the well owner.
repair under#21 remarks section or on the back of Bits 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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled:
_ SUBMITTAL INSTRUCTIONS f
9.Total well depth below land surface: -3-a (ft} f
For mulGple Wells list all depths ifdifereni(example-3Q200'and2Q100) 24a. For All Wells. Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: a i
Iftvater level is above casing;use"+^ (ft) Division of Water Resources,Information Processing Unit,
1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For IDiection Wells: 7n addition to sending the form to the address in 24a
12.WeU construction.method:.- r,s- +cy A e-- above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) �b Method of test Gy p -k-,NL 24c.For Water Suomly&Iniection Wells: 7n addition to sending the form to
v the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i(i�a `I a% 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