GW1--05802_Well Construction - GW1_20230901

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: PirlfFoftn
1.Well Contractor Information: 1Y
Gary Thompson I la.WATER ZONES
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Well Contractor Name FROM TO DESCRIPTION
4418-A 33 k ft. 33-->t E,-t5o, bN 6 6 o-
ft. ft. I F -
NC Well Contractor Certification Number
1S.OUTER CASING(for multi-cased wells)OR LINER(If ap iicable)
Aqua Drill, Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name © ft. I �-7 a ft I c I-2- tn. I S✓v Z,' 9 kg L
e J 16.INNER CASING OR TUBING(geothermal elosed_loop)..
2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL
List all applicable trail construction permits(i.e.IBC,County,State,Variance,etc.) ft. ft 1 in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 17.SCREEN
FROM TO DIAMETER , SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Publie it. ft in.
Geothermal(Heating/Cooling.Supply) sidential Water Supply(single) ti, ti, is
IndustriallCommencial °Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 g. ft* tcwkbwA k� tau t, A % D.
Monitoringi fJ�
Injection Well: °Recovery ft. ft Ckd�.S
ft. ft.
Aquifer Recharge °GroundwaterRemediation
Aquifer Storage and Recovery ..19.SAND/GRAVEL PACK(if applicable)
q g °Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD -
Aquifer Test °Stormwater Drainage ft ft I
Experimental Technology °Subsidence Control ft. ft I
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional Sheets if necessary)
Geothermal(Hcating/Cooling Return) (Other(explain under#21 Remarks) FROM TO DESCRIPTION{caror.tuudness soilleoek type,grain size ere l
4.Date Well(s)Completed: 5`�1� ) Well ID# (D c S ft (-,... 1�'t�.-cjl Sa:,
5a.Well Location: to5- ft D ft. tic p :1.1 y
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Titryw Prole AYN- ...16 ft. "..A.yl.ft Grill„\-Ad•L ,-,8^"°1 di'
Facility/Owner Name FacilitylD#(if applicable) ft ft. F.c Li i V L_Li
it eIJIDwS 0nvC'' V -11 Wk- "7-la Zk ft ft SEP n
Physical Address,City,and Zip ft. ft �� 1 ?`+�
okt..5 21.REMARKS r Ur#
IilJ;r,Ali^;t iJf.^.-G`r m'd'.
County Parcel Identification No.(PIN) tyr3; ;'-r.:
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
0
b (vt SG,T3`1 2 N C° ' 1,1 „5-61 S•f$14 w t,
6.Is(are)the well(s)a-,marten or OTemporary . Signs of eniRed Well Contractor 1 Date
�� By signing this form I hereby certify that the well(s)was(were)constructed in accordance
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7.Is this a repair to an existing well: Dyes or F with ISA NCAC 02C.0100 or/SA NCAC 02C.0200 Well Construction Standards,and that a
Ifthis 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#2/remarks section or on the back ofthtsform. I.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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:
For multiple wells list all depths tf d fferent(example-3@200'and 2@/005 (ft) 24a. For All Wells: Submit this farm within 30 days of completion of well
LID
construction to the following:
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10.Static water level below top of casing: D (ft.) Division of Water Resources,Informadon Processing Unit,If water level is above casing use ' "" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: (e (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: j`ta c Y R1+✓ above,also submit one copy of this form it ithin 30 days of completion of well
(i.e.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
13a.Yield(gpm) ee Method of test: mot,4.`l,1 k kwe 24c.For Water Supply&Inieetion WeI11: In addition to sending the form to
v/ o the address(es) above, also submit one,copy of this form within 30 days of
13b.Disinfection type: \c 1\k l t) Amount: b l7-- 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