GW1--05782_Well Construction - GW1_20230905

___ CONSTRUCTION RECORD 1
For Internal Use Only:' Print"Form
1.Well Contractor Information:
Gary Thompson
Wctl Contractor Namc 14.WATER ZONES
FROM TO i I
4418-A DESCRIPTION
NC Well Contractor Certification Number ®� ��XL 1•e �' j0i`
ni
Aqua Drill, Inc Is.OUTER.CAs®Dtitased'wells OR LINER a •Iicabte
FROM OMEIER Company Namc
2.Well Construction Permit#: ®I 7.,ci 16.INNER CASIN®® S b �,1 w U C-
List all applicable twit construction ®�u1♦ TO thermal closed-loo
permits(i.e.UlC,County State,parlance,etc) DLiMETER THICKNESS MATERIAL
ft. ft 11111=1111111111111
3.Well Use(check well use):
rt. ft in.
*Agricultural
Water Supply Well: 17.SCREEN
*'Agricultural ° icipal/Publie FROM TO DIAMETER SLOT SIZE
■G Geothermal(Heating/Cooling Supply) = MATERIAL
uPP Y) Residential Water Supply(single)
*Industrial/Commercial E3Residential Water Supply(shared)
1111111111111111111611.1111111
Irri ration 18.GROUT
Non-Water Supply Well: PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
"Monitoring 'b ft" -ID R. • '�,
Recovery �.t�ea. w t •.
Injection Well: ft. R. Chi?,e.
MI Aquifer Recharge °GroundwaterRemediation ft. ft.
Aquifer Storage and Recovery Salinity Barrier 19•SAND/GRAVEL PACK(if appllcable).:. .
FROM TO MATERIAL EMPLACEMENT METHOD
it Aquifer Test QlStonnwaterDrainage ft, ft
I Experimental Technology °Subsidence Control ft.
Geothelmal(Closed Loop) ��**��,Tracer '
L.1 20.DRILLING LOG(attack additional'sheets if necessary).III:Geothermal(Heating/Cooling Return) Other•(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,sod/rock type min size etc.)
b ft. l b ftC.
4.Date Well(s)Completed: 4r�71Z v-l) well ID# e, ft. UM,' `,
\� 3 ©rirV.c Sw:ilaleY s b.
Sa.Well Location: 5....
t 1 it. ft. G 1
C tN�aw I°bl6kL tkomxs 4 ft - ft• rA�t e
Facility/Owner Name Facility ID#(if applicable) ft. ft t ° I, ]J f 1 AEiuQl�v'. . I it A/� 61.14.t,S crt.e k. rvi< ft. ft i l l•f' �/ 5ZUEJ
Physical Address,City,and Zip ft, ft
Ckl.tTrxrxt7-'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
w ctor s/�Z� '�+3
6.Is(are)the weil(s). ermanent or oTempOrary Signatureoto txMLtTyWMilled well Contractor Date
� By signing this form,I hereby certifytlatt the well(s)was(mere)constructed in accordance
7.Is this a repair to an existing well: °Yes or R with ISA 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 under 021 remarks section or on the back of this form. I
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: '2 �s� (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200and 2@100' construction to the following:
10.Static water level below topof easing: "f'a I
If water level is above casing,use••+ (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In additionito;sending the form to the address in 24a
,r • above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: nr.vi-i,..)/ A•• construction to the following: 1
(i.e.auger,rotary,cable,direct push,etc.)
• Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: +. 1636 Mail Service Centr,Raleigh,NC 27699-1636
13a.Yield(gpm) �5 Method of test: 0"1." r l'e•-- 24a For Water Snooty&Injection Wells: In addition to sending the form to
{ t i,��„ �(�v�L the address(es) above, also submit one Copy of this form within 30 days of
13b Disinfection type: l� /� Amount: completion of well construction to thel 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