GW1--00305_Well Construction - GW1_20240112

WELL CONSTRUCTION RECORD(GW-1) ( For Internal Use Only: Print Form
1.Well Contractor Information: I
Gary Thompson 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A i'3S". 131 rt. _
ft. ft.
NC Well Contractor Certification Number
Aqua Drill, Inc 15.OUTER CASING(for multtcasedwells)OR LINER(flap licable)
FROM TO DIAMETER_ THICKNESS J MATERIAL
Company Name 0 ft c( ft. l C 1- In. i/ /f/. —
j 16.INNER CASING OR TUBING(geothermal desed-loop) _
2.Well Construction Permit#: J 'I��?��i.N) "1-'3 FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable well construction 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
A CLLltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gn QMunicipal/Public ft. ft. tn.
❑Geothermal(Heating/Cooling Supply) C1i,residential Water Supply(single)
ft. H. In.
9
Industrial/Commercial 18.GROUT Residential Water Supply(shared) —
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: rt. ft, O 1 in/ -
�Monitorin gr-44,v,'Fs. Qirir •', Hi GP'
InjectionMonit Well: Recovery ft. R. Ca 12.E I/ —
QA uifer Recharge ft' ft.
q arge DGroundwater Remediation
uifer Storage and Recovery19.SAND/GRAVEL PACK Of applicable)
Aq g Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft ft.
Geothermal(Closed Loop) [JTracer 20.DRILLING LOG(attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) nOthcr(explain under#21 Remarks) FROM TO DESCRIPTION(enter,hardness,soil/rook type,grata!tee,eta.)
4.Date Wells Completed: 1'?�r"1. � ft. l� � (�'h
() p T Well ID# I D ft. ft. t.„1• Z); So r
Sa.Well Location: ft ft ��cJJ.
Facility/Owner Name -L Facility ID#(if applcable) ft. H.
517
Physical Address,City,and Zip ft rt L tj'�t`- L / C
tt A f+/�ta,t1,"... 21.REMARKS
�
County Parcel Identification No.(PIN) J4N a 2024
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laVlong is sufficient) 22.Certification: ...4.4441 Processing
DWOMOS
6.la(are)the well(s) rmanent or Temporary Signature of ified Well Cot actor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to en existing well: 11111 Yes or O with ISA NCAC O2C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constnuctIon 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:
YouY 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
f _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t `(�7 (ft-) 24a. For All Wells: Submit this fbnn within 30 days of completion of well
For multiple wells list all depths ijdlfferent(example-3@200'and 2(41005
rr construction to the following:
,�
10.Static water level below top of casing: 'b t (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: j` (In.) 24b.For Infection Wells: hi addition to sending the form to the address in 24a
12.Well construction method: C ul"4 by Pb'.! above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.)
A 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) al--j5- Method of test: C P LL AA','het- 24c.For Water Supply&lniectiorL✓�Ils: in addition to sending the form to
, pi O the address(es) above, also submit one copy of this form within 30 days of
i%13b.Disinfection type: T '1D Amount: t I, A-- completion of well construction to the countyhealth department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016