GW1-2023-02944_Well Construction - GW1_20230425

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only: -
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A -LA'ft. - ft. F,-fz4-4 S G p tM
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETE
THICKNESS MATERIAL
Company Name
Y0 R• iLO ft- 61,-, in. 5bikl.t Q1fC-
3� 1 /lv 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit# FROMTO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Cowin;State,Variance,etc.) ft ft. in.
3.Well Use(check well use): It. it. in
17.SCREEN
Iiii
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gricultutal DMunicipal/Public ft. it. in.
Geothermal(Heating/Cooling Supply) [sidential Water Supply(single) ft ft. in.
Industrial/Commercial []Residential Water Supply(shared) i8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ft. Q ( t Vl CO
Monitoring _Recovery ft. ft C k l tots 11 r
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
quifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QIStormwater Drainage ft. ft
Experimental Technology DISubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) ,
FROM TO DESCRIPTION(color,hardness,soil/rock type grain size,err.)
Geothermal(Heating/Cooling Return) (Other(explain under#21 Remarks)
Z) ft. (t7 ft. 4.1,Ii`.,
4.Date Well(s)Completed: LI 1/-13 Well ID# t ZJ R- I,OS ft- (3 7 S b=fit/ s 6 1
5a.�Well Location:9 1 D g' ft lea ft. O fi p s p-b..eQII Se,'1�D\.s r+ It�tiv�Ur�S /420 ft. /4.�- ft G rev.i� t
Facility/Owner Name Facility ID#(if applicable) \4S ft LI.1.s•ft. GC S;(-c
Physical Address,City,and Zip --7,ps.Z ft. it i n fl 2 r 2C23
S ke.1, 21.REMARKS Ht 1A dd 6vf-d
County Parcel Identification No.(PIN) lt R_-,.._,_.e;.,.l Pc..?....-.mm�As�U' k
. ari.. .v._. -
OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � �
(if well field.one lat/long is sufficient) 22.Certification:
36h Ill 01-S131'241X S6°O ' ,,'" 1 i i ?4 t w /-74-1 l-Z"3
6.Is(are)the'well(s) anent or Temporary Signature of ified well aontractor Date
By signing t is form,I hereby rertifj'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Vo with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider#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: "'i - (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd Jbrent(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: ".--.6. (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6. On.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
s r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: M''"--y 0construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) C Method of test: CAt-c-1-1. L,'INc. 24c.For Water Supply&Injection Wells: hr addition to sending the form to
e a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: R\t'1 0 f, Amount: d 6 I'� 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