GW1-2023-02942_Well Construction - GW1_20230425

LL CONSTRUCTION RECORD G r_Y Print Form
For Internal Use Only:
1.Well Contractor information:
Gary Thompson
Well Contractor Name 14.WATER ZONES
FROM TO - DESCRIPTION
4418-A
NC Well Contractor Certification Number
21rj fit --2-rf7 ft rr:,,,4 �.�C. `r
Aqua Drill, Inc. IS.OUTER CASING for multi-cased= wells OR LINER if a..Iicable
FROM TO DIAMETER THICKNESS Company Name a D- 1Li, x�`
in.
2.WellConstrictionPermit#: `(�C_� 16INNERCASINGORTUBING :eotbermalclosed-loo.
List all applicable well construction permits(i.e.Urc•County State Variance,etc.) FROM g• TO DIAMETER THICKNESSft. in.
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN
*Agricultural IMunicipalPublic FROM TO DIAMETER SLOTSILE THICKNESS MATERIAL
11 Geothermal(Heating/CoolingSupply) R 1n _
uPp Y) 'dentjal Water Supply(single)
It Industrial/Commercial fit It ,n _
Residential Water Supply(shared)
�;Irri;•tion 18:GROUT
Non-Water Supply Well: FROMTO- MATERIAL EMPLACEMENT METHOD&AMorm
b fit 2� fit•
!Monitoring 'Recovery Oo'�`,. rJ
Injection Well: ft. ft• Ch$1,
*Aquifer Recharge QGroundwater Remediation ft. it
IliAquiferStorageandRecovery oSalinity Barrier19.SND/GRAEL PACK tfa liable
*Aquifer Test FROM To MATERIAL EMPLACE METHOD
°Stormwater Drainage ft. ft.
1111 Experimental Technolog
y °5ubsidence Control fit ft.
*Geothermal(Closed Loop) iiTracer
Geothermal 20.DRILLING LOG attach additional sheets if necessa
(Heating/Cooling Return) i i Other(explain under#21 Remarks) FROM TO DESCRWIION color hnrdaea sell/rocke, min size,etc)
4.IDate Well(s)Completed: 4~j 7`� ft ! G I A,
Well ID# � ��
Sa.Well Location: I O <oo ` y Say^c�� 3a 1.
) .�5/:f-tA WII �az, d 6R lJd�3�l(� — ' 1I 1i f+nr k
Facility/Owner Name 3lS lKy` ft. tt
Facility mu(if applicable) y�ft. 3 fr.
k1`t t�b`2 / +bl l�t(Ary r`�y� Jr L fit ft.Address,City,and Zip 6 it..
ft
% �`p 21.ItEMARFC FA 7 93
County ,
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _ A:I pi;'G. .a fl i
(if well field,one lat/long is sufficient) DWQti'+Oti
? 0 7d �� 3 C6 02't F �' // 22.Certification:
6.Is(are)the well(s) manent or `f /� 7 Temporary Signature of nco wen c b5ttractor Date
7.Is this a repair to an existing well: dyes or By signing this form,I hereby cert •that the well(s)was(were)constructed in accordance
with ISA
If this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided toAC the well owner.
0Well Construction Standards and that a
repair under#2I remark.section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPF 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 TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface:_ J STT�aSTRUCI7[ONS
For multiple wells list all depths Ifd fferent(erample3(a�1Q0 d 2 a©100) (fit) 24a. For All Wells:_-
wing: this form within 30 days of completion of well
10.Static water level below top of casing:— rj 6 construction to the following;
I10.ter el is above op (ft) Division of Water Resources,Information Processing Unit,
1L Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-I617
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: EQ 4y,,.y i3; above,
nstr also submitothone copy of this fonts within 30 days of completion of well
(Le.auger,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
132,Yield(gpm) ••-2.,_S- Method of test: /4 1'Lit '�
'rye. 24c.For Water Supply&Injection Wells.
a the address(es) above, also submit one copy• addition In hs formto sending theform to
13b.Disinfection type: s7 o:_ Amount: I C r% this within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form OW-I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016