GW1--00079_Well Construction - GW1_20231228

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WELL CONSTRUCTION RECORD(GYRE-Il) For Internal Use Only:
1.Well Contractor Information: •
Gary Thompson 14..WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
4418-A 1-.31 ft. 1-3 47 ft' Cried/do' C c,rei
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi cased wells)OR LINER(Nap licable)
•
Aqua Drill, inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q IL 4 / ft. G,)5- In. I/5,5, _64
7)6,/
16.INNERCASING OR TUBING-(seothertaal.dosed-loop)-
. 2.Well Construction Permit#: 5-%>7 5- Y 1-1-- FROM TO DIAMETER THICKNESS MATERIAL `
List all applicable well construction permits(i.e.UIC,County,State'Variance,etc.) R- ft. ' ,in.
3.Well Use(check well use): ft. ft. ln.
• Water Supply Well: 17.SCREEN
FROM TO - DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural °Municipal/Public ft, ft. In
Geothermal(Heating/Cooling Supply) residential Water Supply(single) R. ft In.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. 2>j ft. ,L
fl.14ti>�.�f 6Arat„r 13 I440
Monitoring ()Recovery ft. ft. CArio,y
Injection Well: R. it
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable) .
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stonmwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft. I
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets If necessary):.
Geothermal(Heating/Cooling Return f Other(explain under 821 Remarks) FROM TO DESCRIPTION(mlor,luedaess attire ktype,wain eke,eta)
d ft' 16 ft Cl/Ry
4.Date Well(s)Completed: t11-13'lb Well ID# (p IL lip f PI Sot.01
5a.Well Location: ti b ft. 44 ft;. �Y •
�,ir.4w..�C
It: ft ! s 4`
Factlity/Owner Name Facility]Dil(if applicable) S- ft. "'' °n �.,4.t A �
.S"4'la6 0/1 vt.1.e..(L,J. Ace. '(Suit, b'►.c,• ft. tt. DEC `� 2!!?1
Physical Address,City,and Zip "-'13 i 1,- ft ft Ir•tC ,-r•P'i.^.n TD,.,-_
11AY►�6,�a:�t` 21iREMARKS, ' . h,F,- :.-v.t: UPI�. a
County • Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(If well field,one lat/longis sufficient)
22.Certification:
3S"d,5/ '."7 T6'r N a f 5`0 312„ W
41..„.72...........- . : .. et...7-0-4.1.3
6.Is(are)the well(s) ermanent or Temporary signature of ed Well Contractor . Date
By signing/this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: °Yes or [La co with ISANCAC 02C.0100 or 1SA NCAC t12C.0200 Well Construction Standards and that a
If this Is a repair,fill out known well construction information and aiplain the nature of the copy of this record lies been provided to'the well olvner•.
repair wider#21 remarks section or on the back of INS form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Youmay 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: '3 6 3 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdperent(example-3@200'and 2@I00) construction to the following: 1
10.Static water level below top of casing: 3 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" c 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter. 47 (In.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
• above,also.submit one copyof this form within 30 days of completion of well
12.Well construction method: (`►ii)a r y µh >' construction to the following: 1 y p
(i.e.auger,rotary,cable,direct push,etc.) 1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,'NC 27699-1636
13a.Yield(gpm) (6. Method of testi <td ci i f I. e.. 24c.)For"Water Sainnly&Iniecti(ri'Wells: In addition to sending the form to
_ 6 the address(es)above,also submit lone copy of this form within 30 days of
13b.Disinfection type: i./(�M 7vee Amount: • it • completion of well construction to the county health department of the county
. where constructed. 11
1I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources • Revised 2-22,2016
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