GW1--05932_Well Construction - GW1_20230918

WELL CONSTRUCTION RECORD GW-1 I Print Form
For Internal Use Only: _
1.Well Contractor Information:
Gary Thompson
10.WATER ZONES
Well Contractor Name FROM _ TO DESCRIPTION
4418-A _ Sr ft. 573 ft- ('rfti..(U Co 01 Cu isrV
ft. ft. -
NC Well Contractor Certification Number
Aqua Drill, Inc 1S.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM f TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. l '.7ft. 4,1 7 in. 5 I::fL1, 0(l`
(� +�r-� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: P I"e k'0 L 7��-o t I Lip FROM TO DIAMETER-1 THICKNESS _ MATERIAL
List all applicable well constuction permits(i.e.WC,County;State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
AgriculturalFROM TO DIAMETER SLOT SIZE .1 THICKNESS MATERIAL
DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single)
ft. ft. in.
Industrial/Commercial QResidential Water Supply(shared) I
18.GROUT
irrigation FROM TO MATERIAL -1 EMPLACF,MF.NT METHOD&AMOUNT
Nun-Water Supply Well: 0 ft- 10 ft.
Monitoring QRecovery ft. ft. t.hN,
Injection Well:
Aquifer Recharge DGroundwatcr Remediation ft. ft.
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry DSalinity Barrier FROM TO MATERIAL
EMPLACEMENT METHOD
Aquifer Test ❑IStotrrtwater Drainage ft. ft.
Experimental Technology QSubsidence Control ft. ft.
Geothennal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size.etc.)
C ft. t b ft
L Ifoi.l
4.Date Well(s)Completed: ° .tea'.t`- Well ID# 1 D ft' `7 bft. Dry .=1
p
` •/
5a.Well Location:` t 7 ft. ‘...1,S ft. �,,. "[
1 „,;tiv, -& I- iu-Lv.._ -7Sft. 47 <ft. Cl-Pi. Z
Facility/Owner Name Facility ID#(if applicable) ft, ft. i
l� [ ft. ft. ...
-T
(Jo `c'�:� S-:�p�' 't�7\rid•, yv 4.._
Physical Address,City,and p ft. ft. 1
S Lt-c.- \'
�i 21.REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) -
�!-ti r t, t dt 22.Certification:
'`.25 3r S, ( 76 IN 11) -3 t .c I , t I l. w ,�'
6.Is(are)the well(s) Permanent or Temporary Signature of tific f Well Conttacto Date
By signing this form,I hereby curt('that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or f'o with 1SA NCAC 02C.0100 or 1SA NCAC(DC.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#21 remarks section or on the back of this form.
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 OW-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: (ft.)
For multiple welts list all depths ifdii ferent(example-3 200'and 2 tt 100') 24a. for All Wells: Submit this form wiihin 30 days of completion of well
construction to the following:
'J•
10.Static water level below top of casing: 1 C (ft.) Division of Water Resources,information Processing Unit,
If water level s above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For injection Wells: In addition to sending the form to the address in 24a
1 ►d: `� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: °r61'ja t-1
(i.e.auger,rotary,cable,direct push,etc.) l construction to the following:
i FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
rt"
13a.Yield(gpm) Method of test: <a,i-'t..I I.°'r C. 24c.For Water Supply& Injection Wells: In addition to sending the form to
/ r,` the address(es) above, also submit ore copy of this form within 30 days of
13b.Disinfection type: VT(-.7°-v Amount: ((e / 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