GW1-2023-02925_Well Construction - GW1_20230420

LL CONSTRUCTIONRECORDGib,Il Print Form
For Internal Use Only:
1.Well Contractor Information:
Gary Thompson .
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
4418-A -...o5-ft. .-.. 1 ft. cr P0 6''-' i '1-6 e r
ftNC Well Contractor Certification Number ft.
Aqua Drill, Inc. IS.OUTER CASING(for multi-cased wells)OR LINER(if ap liable)
FROM 11 TO � t"�%DIAMETER I THICKNESS MATERIAL
Company Name D ft G-2- ft I ZS in, 15o.f--2-k- p
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,Comely,State,Variance,eta) 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
..icipaVPublic ft. ft in.
Geothermal(Heating/Cooling Supply) iiResidential Water Supply(single)
Industrial/Commercialft in.
QlResidential Water Supply(shared)
' Irrigation IS.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Monitoring a fr. "za ft (31^ Cl.o(z :r,• k-\�
oRecovery ([�•
Injection Well: ft• ft Gti;ps a
Aquifer Recharge DGroundwaterRemediation ft. ft.
Aquifer Storage and Recovery QlSalinity Bather 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology °Subsidence Control ft.
ft.
Geothermal(Closed Loop) °Tracer
20.DRILLING LOG(attach additional sheets if necessary)
FROM Geothermal(Heating/Cooling Return) {Other(explain under#2I FROM TO DESCRIPTION IPTION(color,hardness,soil/rock type,grain size,etc.)
4.Date Well(s)Completed:3 J WeilID# ft. t
Sa.Well Location: , c-s �+ i( 1' r t_ks, 56;k.
S� 6-1—ft' bra,.:-V .
\--dr`�) �.e.N g,-n,., 62 ft' -2_65 f' ?
Facility/Owner Name `7''�� -__
Facility Mit(if applicable) ft. ft I,,. .. -;`-
l lD ��E aS t"�o C ,:cm c rv{v:� 'NC-1.7a�`N ft. ft
Physical Address,City,and Zip ft. ft. APR 2 6 1 i z
��-S 21.REMARKS J
County f ii;_ i:v ,,:1 i
Parcel Identification No.(PIN) =J .S e,l
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
�4'b I / S�,h i t Ld c t 22.Certification:
s`—' "3-- .13
6.Is(are)the well(s) rmanent or C3Temporary Si of Rifled Well Contractor
Date
Yes or �'signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
If this is a repair fill out!mown well construction information and explain the nature ofthe copy of this record has been provided to the well oNCAC 02C wner.ell Construction Standards and that a
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 GW-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: •
For multiple wells list all depths ifdifferent(example-3@a 200'and2@100) ( ) 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: .5'6
Ifwater level is above casing,use"+^ (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `o Cn.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r"u t(,e,r y •, above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 1 construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
l 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l Method of test: t`,M k c-
� �. / 'f?7'�I�>'. 24c.For Water Sulu*,&Infection Wells: In addition to sending the form to
13b.Disinfection type: 1- (� �!D Amount: ��2 the address(es) above, also submit one copy of this form within 30 days of
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