GW1-2023-02923_Well Construction - GW1_20230420

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Form`"
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
4418-A 7vo t�a cr rc:Fv� �(,e
NC Well Contractor Certification Number ft ft.
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. Tv ft G.Z.S in. Stotom1% J kpLiL
��••,j', � 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: p 1" 1. FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in
Water Supply Well: 17.SCREEN
Agricultural . FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft ft. in.
Industrial/Commercial OResidential Water Supply(shared)
Irrigation IS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water.Supply Well: ft 2321 ft n 6 �`
Monitoring
Injection Well: [°Recovery ft ft. `l::rs Y V y
Aquifer Recharge °GroundwaterRemediation ft. ft.
Aquifer Storage and Recovery °Salinityliatiiet 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft- ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
["Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.)
Geothermal(Heating/Cooling Return)
a ft, tb ft, C.k ay
4.Date Well(s)Completed: 14"S - Well MN 19 ft. 'a ft. , r
• 5a WellLocation: co ft ?41 ft. C.e A`.b�e.-.•
BC-kb t/CItr Sgft. /6'5ft.
CaCrosw'1.
Facciilitty/OwnerNam[e' (� (1 (,� Facility ID#(if applicable) ft• ft.
�Jo�1v` -•�4.�' 4'�tlrt X F./INN ft. ft • - • :_,..,,,�
Physical Adders,City,and Zip ft. ft.Mitt t•^�� 21.REMARKS �.ftfu
. ) 9 '1()•)'�
County Parcel Identification No.(PIN) L L
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i1'" ""''"'� `5' ..7.:;:-.3 Una
(if well field,one latllong is sufficient) v
/ 22.Certification:" 1>/34.eft b
44 4 e' N I '-)'b 3 k oC)L1 .Cr ly t t w .Cju✓1 11 .ys.�� �(r>,^L----)...."36.Is(are)the wells) Permanent or °Temporary Signature ofiCertified Well nGb tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this)a:repair to an existing well: °Yes or No with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Ill out known well construction information and esplatn 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 forin.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You mayuse the back of this page to provide additional well site details or well
construct on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
•�/ SUBNIITTALINSTRUCTIONS
9.Total feii depth below land surface: ( ) 24a..For All Wells: Submit this form within 30 days of completion of well
Formuhip wells list all depths ifd erent(example-3 a200'and 2Q100�
construction to the following:
10.Stati water level below top of casing: 'SD. (ft) Division of Water Resources,Information Processing Unit,
If water Teel is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bore ole diameter: 4? (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well onslruction method: (-5a c-.0/ 12. above,also submit one copy of this form within 30 days of completion of well
(Le•auger, tary,cable,direct push,etc.) ( construction to the following
FOR WAITER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yiel¢(gpm) J Method of test: C',4-t-L '°C 24c.For Water Supply&Injection Wells: In addition to sending the form to
T the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: v es Amount: i‘ /� completion of well construction to the countyhealth
p department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016