GW1--00344_Well Construction - GW1_20240112

i
I
WELL.CONSTRUCTION RECORD(GW-1) For Internal Use Only: —Prf if Form
1.Well Contractor Information: +
I
Gary Thompson 14.WATER ZONES
i Well Contractor Name FROM TO DFSCRIp1[ON
4418-A • 1db ft. -Los- i. crec.J-t— - ,-1) Gp0^
ft, ft.
NC Well Contractor Certification Number I
IS.OUTER CASING(for=untested wells)OR LINER Ofap liable)Aqua.Drill, Inc FROM TO' DIAMETER THICKNESS MATERIAL
Company:Namc a I 61.R• 1 t!a,�5'•'.in. I
5010A put
•^-�, �v� � 16.INNER CASING OR TUBING(geothermal dosed-Loon)
d
2.Well Construction Permit#: 47/3 FROM TO DIAMETER TIRO/CRESS MATERIAL
List all applicable well construction permits(l e.UIC,County,State,Variance,etc.) ft. 1t. M.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: 17.SCREEN.
•
0Agricnitwal FROM TO - DIAMETER SLOT SIZE THICKNESS MATERIAL
�Municipal/Public ft. ft. In.
. °Geothermal(Heating/Cooling Supply) idential Water Supply(single) tt, n In.
°Industrial/Commercial °Residential Water Supply(shared)
IS.GROUT.
•
M gation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: d tt: ft. h,f'�t I+ p, —
Monitoring Recove
Injection Well: •
ry ft• it. tl;,�S
Aquiferft. It,
Recharge °GroundwaterRemediation
Aquifer Storage and Recovery 19.SAND/GRAVEL,PACK Otapplicable)
• g ry °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD ..
Aquifer Test oStonnwater Drainage ft. ft.
•: Experimental Technology °Subsidence Control IL ft.
Geothermal(Closed Loop) D1Yacer 20.DRILLING LOG(attach additional sheets If neceasary) - -
,Geothtxmal(Heating/Cooline Return) f Other(explain under#21 Remarks) FROM TO DESCRIPTION(colon hardatn eeWraek type pieta else,era)
4.Date Wells)Completed: "Li"2/1Weil DINT tS 5� l o i IL r
Sa.Well Lando •: S� 61- IL �arOr•1''lr
Aa`, �p 6z ft. Z�‘ tti Gr'pa;t b...Fact•tylOwnerName Facility IDS(if applicable) ft. ft.
S74 Colo o lv t A 1 .ktso R<s};m/s�+134Ai•�✓ �t ft. IL n r. y
>r-:, r .;"`g tit' "'i
Physical Address,City,and Zip ft. ft.Rh146tpk • 2l.REMARKg' = --.iahl ll 4 SU24
County Parcel Identification No:(PIN)
ind 1rtfCriT,•PA4Z:l r.`�" ".:vj!'1'
longitudeS6.Latitude and
egreeshninutes/seconds or decimal degrees: D,.,/u 3,�; _
(if well field,one latilon is sufficient) 22.Certitication:
= sba4•' 1, 's i411 N 716 Lie' i 1.:. a- ti W
6.Ware)the welt(a) ermanent or Temporary Sig of ed Well tractor. I Date
��� By signing this form,I hereby certify that the well(s)s as(were)constructed in accordance
7.Is this a repair to an existing Eil"well: ®Yea or a with ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is arcpair,fill out known weilconstmctlon information and explain the nature of the copyofthis record has beefl provided to the wall owner:
repair under#21 remarks section or on the back ofthtsfomt•
23.Site diagram or additional well details: •
8.For Geoprobe/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: S (tt.) 24a.For All Wells: Submit this form within 30 days
For mtihiple wells list all depths iifdii ferent(example-3@200'and 2@100' of completion of well
y_, construction to
10.Static water level below top(leasing: •�•t f{
If magi.level is above easing;use"+^ ( ) Division'of Water Resources,Information Processing Unit,
,r 1617 Mail Service Center,Raleigh,NC 27699-1617
II:Borehole diameter: C� (ID.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Wed construction method: Pottlr i( �•i e• above,also submit one copy of this jform within 30 days of-completion of well ,
(Le.auger,rotary,cable,diieot push,etc.) construction to the following:
Division of Water Resources,
FOR WATER SUPPLY WELLS ONLY: vies, ent ergroung ,NC 27 9-1 36 Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 b Method of test: C iakh1 lok^C 24k.For Water Sounly&Infeetior Wells: In addition to sending the form to
I �' D the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: A Amount: I (p d�2. completion of well construction to the comity health department of the county •
where constructed.
Form OW-I 'North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016