GW1--06308_Well Construction - GW1_20230926

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information: i
Gary Thompson _ 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A Igo ft. tem ft. c 94-- -Z t,r re.,
ft. ft.
NC Well Contractor Certification Number
1S.OUTER CASING.(for multi-cased:wells)OR LINER(if ap•licable)
Aqua Drill, Inc FROM TO DIAMETER THICKNESS I MATERIAL
Company Name 0 ft. vut, ft 6r'XI. in. 50N".,L P%C.
16.INNER CASING OR TUBING(geothermal clased400p)
2.Well Construction Permit#: -1-2661 'II 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnuction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. In.
Industrial/Commercial DResidential Water Supply(shared) 16.GROUT
Irrigation - FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rl ft. "4d3 ft. p �l�r : 1
Monitoring ,P rJv L..e y�• ,
E3Recovery ft. ft. CiNI s
Injection Well:
Aquifer Rechargeft. ft.qGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QlSalinity Bather FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,sa;uroekeype,grain size,etc)
ft. l t5 ft' C ti,a�� .
4.Date Well(s)Completed:ilil„--u` -0 Well ID# ft. ft ! 1
�~' fit. 'fie,.. Sloa.3.y ac: P.
Sa.Well Location: ll;- 2 t a ft* je,E'
tli
f
gip(.p (.. esi,_,64.a,\•,) t ft v ft. 1 xA ft. G taw;1-zse
Facility/Owner Name Facility lV#(if applicable) i tb ft. 7,tIV.t G ^'i,a_
2?'-? l.=i �, I.ayam'Ut t R.t:� .4. ft. ft. T '' n I: v Iti,5-`1
a .4�s t t ;
Physical Address,City,and Zip ft. ft.
hrr 21.REMARKS SEP d �(; ZU f'�
County Parcel Identification No.(PIN) C
in degrees/minutes/secondsIn'D"r.cD rir' "•,`'e:3 Ur"
5b.Latitude and longitude or decimal degrees: r•••.•.«;,-.•.
(if well field,one Iat/long is sufficient) 22.Certification:
W5.?\ •75l✓Y4rbZN 96 - t C 2 j/ W
4iik4 ,�,• '-_ ' D- r -7.�6.Is(are)the wells) ermanent or Temporary Sigfcehiti Welt Co for t Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 111 Yes or �No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this Is a repair,fig 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 an the back of this form.
23.Site diagram or additional well details:
8.For Geoprohe/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: -)-k (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list.all depths Ifdifferent(example-3(.200'and 2@100') construction to the following.
10.Static water level below top of casing: 1°6 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
a
11.Borehole diameter: to (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
- above,also submit one copy of this form within 30 da s of comp
letion of well
12.Well construction method: 1-4-ht.'L .� construction to the following: 1 y p
(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) .-$ Method of test:Ck.'c.L- \tmv 24c.For Water Supply&Infection Wells: In addition to sending the form to
c, the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: l-kT'v\� 4 Amount L f7_ completion of well construction to the county health department of the county
where constructed. I,
,
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016