GW1-2023-02795_Well Construction - GW1_20230417

ILL C®NSTR�JC1`I®N RECORD(GW_g PrirltForm
For Internal Use Only: '
1.Well Contractor Information: I
Gary Thompson
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A I(Zs ft' I C.`-t ft. crwcki, (0 (Dr
vaN-
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. IS.OUTER CASING(for multi-cased wells)OR LINER(ifap Iicable)
FROM TO DIAMETER THICKNESS MATERIAL
CompanyName b 11 I to S ft 1 G i, S ia-• 5 O(k,,s..t. 1.4 is
- � 16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable sell construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
3.Well Use(check well use): g,
Water Supply Well: 17.SCREEN
jg Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0Municipal/Public ft. ft. in.
*Geothermal(Heating/Cooling Supply) Eliggidential Water Supply(single)
ft. in.
II Industrial/Commercial Residential Water Supply(shared) 18.GROUT
i Irrigation
FROM TO MATERIAL EMPLACEMENTS METHOD&AMOUNT
Non-Water Supply Welk
v & -Z-D ft' r i
*Monitoring °Recovery ��...:c. �6`�r ti��t�
Injection Well: ftIt « per
*Aquifer Recharge [GroundwaterRemediation ft. rut
2,t. S
*Aquifer Storage and Recovery Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MIATERIAI, EMPLACEMENT METHOD
*Aquifer Test ' 'StormwaterDrainage ft. ft
*Experimental Technology . E3Subsidence Control ft ft
*)Geothermal(Closed Loop) Tracer
20.DRILLING LOG(attach additional sheets if necessary)
- *Geothermal(Heating/CoolingReturn) *Other(explain under#21 Remarks) FROM TO DESCRIPT[ON(co[or,r,udness soSurocktype erafasire err.)
1, 0 ft• t f• CU,
4.Date Well(s)Completed:'6`l '�� Well ID# to ft: 7 ft Del h,.�� M
5a Well Location: s.`Vee t
�' FL �J ft (,..1,..:1- yiawei So [
AaNc.,-,!bc c- „ play«..._. 94. ft. g ft: Irv,..*!
Facility/Owner Name FacilityID/I(if applicable)_n 25- ft. -2.."A.1-ft. Ctvi-.' c
CO cos k"�4 ii- RAO. 4-,%i t t s.)S IA p-dri INIC. ft. ft.
Physical Address,City,and Zip ft ft
:�
N(� 17`; r t: o a:S
i-0sCASb•1 21.REMARKS
County Parcel Identification No.(PIN)
A P R 1 7 ?0 73
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1st/long is sufficient)
'a .b 1 22.Certification: Ifl';'3i7.:i,'. �i:'_'.r',:..:;':3 ta,.,
4�4G 3i., 3Z �� 'iry z1..
�4 i ,`7"�`I�'tyt G `;C1 '.:H:-
6.Is(are)the wells) Permanent or °Temporary Signature ofCe ' ed Well C tractor y I��
Date
7.Is this a repair to an existingwell: Yes or By signing this form,I hereby cermifp that the well(s)was(were)constructed in accordance
o with ISAIVCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out/mosat well construction information 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 ofthdsform.
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-I 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: 'D=-Z
(ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths/fdrjjerent(example_3( 200'and 2(a3100)
construction to the following:
10.Static water level below top of casing: 5-6
Ifwater level is above casing,use"+" ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (A 014
24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: t'O A A 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:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,6 Method of test: La1,...%---A,V.1>-v--
24c.For Water Supply&Injection Wells: In addition to sending the form to
136,Disinfection type: t4 �D� o the address(es) above, also submit one copy of this form within 30 days of
tl Amount: Le- - . 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 212-20I6