GW1-2023-02801_Well Construction - GW1_20230417

Print Farm
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I"`-�-j
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES 1
1TIe11ContractorNeme FROM TO DESCRIPTION
, 4418-A 3`1bft �,ll�.ft: fit- :t,�-- i-rU (�e
R. ft I
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft. �C it C.�� in. G,D�Zl ,7 VC
�q� ��'p �,,f 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ...0 X_�l�J i-C FROM TO DIAMETER THICKNESS MATERIAL
List all applicable mil construction permits(i.e.UIC,County,State irariance,eta) fL ft In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural EtMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) BICsidential Water Supply(single) ft. ft in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AIItOr1NT
Non-Water Supply Well: ft fe. , f
.Monitoring , Recov �? jcw nrvl ¢?UL.r C ��S`� �1tii .
Injection Well: R
Aft.ft. ft.
q �e DGroundwaterRemedialion
_Aquifer Storage and Recovery gales Barrier 19.SAND/GRAVEL PACK(if applicable)
tYFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStonnwaterDrainage ft, ft.
Experimental Technology OSubsidence Control ft ft.
Geothermal(Closed Loop) DiTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(cetor,hardness soil/rock grain sGs etc.)
0 tt t b ft C ikttl
4.Date Well(s)Completed: `�O'"-�.s Well IID# i,0n• ft. 01 e
Sa.WeliLocation: r ft ft. � �ll Stet l
/�ly //�//i�er �! _1- .� v�
Bc"flGl, 7413c�11�+./ 9b R. 'i'S'-. ft.
AIL, �CMsa•4-.
Facility/Owner�yNNaame C /� Facility Wit(if applicable) ft ' 7c•, tt )I t f
` 3 COIN'', -F'r- 1"dY wA ldt-A- t+� 1v4.�70ct ft. ft Li 2... �y . L. ,
Physical Address,City,and Zip ft. ft --'r - - f Co
rski 1t� i a <s'�4....a rFN'
21.REMARKS p /II
County Parcel Identification No.(PIN) APR 71 ti L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: - ' !
(if well field,one lst/tong is sufficient) i G = -'
22.Certification: ;A'i Qi f-,1 C4
3 2 A1, 515o4/ N So /, _.5 r/S,' ;''j w
6.Ts(are)the wel(s) erinanent or.Temporary Si„.' fC.;fled Wet[t fintrecror Date
By signing this form,I hereby certify that the well(s)was(here)constructed in accordance
7.Is this a repair to an existing well: DYes or El< with ISA NCAC 02C.0100 or 15,4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature ofthe 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: J 6 c (ft.) 24a.For All Wells: Submit this form within 30 days
For multiple wells list all depths ifdf ferent(example-3 200'and 2QI00) of completion of well
construction to the following:
10.Static water level below top of casing: O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casingtser+' 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: to (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:" 4`6k r<ts\I A.,t' above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) G construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 6( i'P Method of test:J tatit..4 tlyv Xs, 24c.For Water Suup1v&Injection Wells: In addition to sending the form to
et-k 27`'1 o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection
type: e9.0 Amount: t c'21 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
I