GW1--02862_Well Construction - GW1_20240510

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WELL CONSTRUCTION:RECORD(GW-1) ' For-Internal"Use Onl . ' n •
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1:Well Contractor Information:
. ' :Gary.Thompson,
• 14:WATLrR ZONES _. ' _ . . {- .t
FROM: ; TO'. DESCRRl1ZON1
:well eontractorNamo ' .. ���E
4418-A �a:
• • aoo�. •a • tarn. :1.-• farPt1
- . NCWeII.ContractorCertificationNumbet'• - IS.OUTER CASING(forniulfeued"we}G)OR-LINER(lion IIcable):..> :- _.:
• Aqua Dii11,1nc. .-ft, ". FROM" -TO• IAML'rLR TffiCt�89 MATERW.
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CompanyName ;
. . DIAMETER,a .. .
�/6 i6INNERCASINGORTOBING(ae -rmalelaxdloop) ` _
2.Well Conahnclion,Permit#:• Iell 1' .. FROM To: THICKNESS. MATERIAL .. •
• List all appllcabre.xrl!construetionp Ut Co ermits(I a C, �.Stai etc e darlwuz .) : :R• -
.." • it. I,le.
3:Well Use(checkwell use) .: '
17 SCREt l . .
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• - DIAMETER_i sLOt'61ZB.. .77itcYlvFss afATERtAL. .
Water SnpP1Y•Welle: . ::-. ;.•. :. .• .PROM To ,
• Agiioultmai " :• . .DMu niciallPubpbc - -
• • .. Geothermal.(Heating/Coolhig"Supply)• Residential Water Supply(single)'. tL .• rt.-- , -. tn.' • • • .
IndustuaUCommercial '- DRes_idenhal Water Supply(shared):• i - ; .
.:• Irrigation . .. . . • .. "".. . ".. . -. . . -
FROM TO MATERIAL" EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply;Well: • : • • ' . . •.• • • . •
onttonng . . • ; ..• ORewVCTy
Injection Well: — -
arfer ecibarge•- ` • Dcandwater •Cern ' ron• , • ' •�
_ • _R PACK(if
e) -
A Stiige aria Recovery . �paimriyBaA1 ' • FROMTOO MATEiA- EMrLAc66nxrMEreoDry
AquiferTest.:. DStonnwater:Drainage:.: : . .
. • BxperimentalTechnology: OSnbsidenceContml. ' " •
" .- • . • ,. Tmicer• •• . • ••. •21L DRILLING LOG(attaeh eddeloaal sheets ifnr nary). :
Geothelmot(Closed I;aap) �. •• •. FROM TO •' DESCRIPTION(color tnrdaai,mtV�ck 4PGt�rla4 ela)"
Geothermal(licatmp/Ccoling Return)• .f Othcr(explain linden#21 Remadts)• •Q . 5 Cl
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y
• ' 4.Date Weu(s)Completed:3"3O':21094 WeH•ID#• • • 5 ••ir:
" : Se.We0'Localion. : . • 35-.
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Carak;llwee d Facrfns' ' ' 40:: .6.05.'.• frro•r►ti�•e _
Focilityl0rvnerNo• � FacilityID#(ifapplicable)
:Vic eiri.-: • tkiAt C )Utc". PiI(O a� :NC �f1
ehisicgAddiOs,city,anti ip - - _R- .- . n • .•.
" , • • 21:REMARKS•
C unty Parcel Identification No.(PIN)
• Sb Latitude and longitude in degrees(minutes►seconds or dec•imal degrees: •. . •' •-. `•" •- • - ••. _ . - "
•• (if well field,onelatllongissufficient) . •_ ' • ' :. '_ • . •22:Certification: ..
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36.1413.13`' N 0c9:o�aI.f`° w... :
•6.1s(are)the wea(sj(PernIanent or [I Temporary'. . • • s of eH Conrmc , i, _ pate...
By,sighing this form'l hereby certity that:the ire11(s)ivas(were)constructed fn accordance _
• • " ifs this qrepstir to an eaisting well: •DYes :or ONO -. . with. or! , ' ..lSANCAC 02C:010D SANCAC U2C.0200 fYell Construction Staiidords and Hurt o
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• !Phis is o repaid fill outfmoivn wellconstrrrction hifoniratldn tied erplaln the riatiuer2/'tiie mpyojthts beenpiiovtded • ' •
repairunder#2lremarlSsectionoronPiebackofthisform:.• has• lathe tnii.:'a .. . •- 't3.Site diagnut or additionalwetl detals:- '
-• : 8.For Geoprohe/DPT or Qosed-Loop Geothermal:Wel s••having the same . You.may rise the liatlr of Bus page to provide additional;Well site details or-well • •
construction,Only 1 GW.1 is needed. Indicate TOTAL NUMBER of wells•- . baron detat'ls Yon may also attach additional pages Wriecessaty.
drilled: - . . - - _ - • - - •SUBMITTAL:INSTRUC'FIONS
. • 9:Totalwell depth below land surface: • :6D.5# ( .).:24a; or All Voile,' Submif this foam within 30'days of completion of well
: Forinultiple wells 1lsfall depths(fdIfcrenl(example-3(9200'and2Q1o0')..' . :.. .
consnnctiontothefoll I.. oawg. .- ..
• • r •10 Static water level below top of easing S0 • (f) Division of Water Resources,Informs tion Processing Unit, ..
Ijxntcr!eve/it-above easel,&use"`+".• • '. •:- . • • - -•- • 1617-Mal Service Center,Raleigh,NC 27699-1617 " • • .
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it Derehole diameter: :b • (in.)' 24b.For infection'Wells:, iddition to•sending the form to the address in 24a• :•.
above;also submit one"copy of.this form within'30'days of completion of welt
• 12,Well emistractlon method: •.- >R O.�a1 C 7 • ' - . • ' ction to the'following:. j
(i a'auger,'rotary,sable;dheot'puslr,etc:).. . • ..
- . - • -• Division of Water Resources,Underground Injectionn:Control Prog'ani, -
FOR WATER SUPPLY WELLS ONLYo• • • - • • • 1636.Ma1l Serviee1Center,Raleigh,NC 27699-1636
13a.Yield(gpm) •- . • I'. - Method of tom.. "#Cell ch.*'ttivte • 24c.•For Water Snuff l'v 1 Injection-Wells:.in addition.to.sending the form to:
•• ti ••• ' the address(es)above;also submit one copy'of this.'fom within 30:days'of
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• 13b Disinfection type. '141 I •1p b Amount; •. • -16 02 completion•of well.constr6cticn to the county health department of the.count.
where Gonstruted. -• •
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Form'GW-1 North c elms Aepartment of Environmental of water ltcsowcxa Revised 2-22 2016