GW1--03293_Well Construction - GW1_20240603

WELL CSTRUCTION RECORD GW_i Print Form
ON
For internal Use Only: -- - -.
1.Well Contractor Information:
Gary Thompson
WWI Colman),Namc 14.WATER ZONES
FROM TO DESCRIPTION
pis-a M • GPM
c. •
NC Well Contractor Certification Number1111111111110
Aqua Drill, Inc 15.OUTER CASING for malt!-casein wells OR LINERable
FROM TO DIAMETER THICKNESS MATERIAL
PNI
Company Name (� H. SS fL 611,4 ,n
°��i5yt� soRa�
oo
2.Well Construction Permit#: 16.OMNER CASING OR TUBING •.;;;Thermal closed ES
List all applicable well construction permits(i.e.WC,County,State,Variance,etc.) FROM ft. TO DIAMETER THICKNESS
MATERIAL
ft• in.
3.Well Use(check well use): R. ir. ;n.
Water Supply Well: 17.SCREEN —
FROM TO DIAMETER_
MI Agricultural 0 Municipal/Public SLOT SIZE THIC KNESS MATERIAL
�'Geothermal(Heating/Cooling Supply) ft. ft,
in.
PP y) Dif Residential Water Supply(single)
it Industrial/Commercial ft R in'
Residential Water Supply(shared)
111
Itri:ation 18 GROUT —
Non-Water Supply Well: FROM TO MATERIAi. EMPLACEMENT METHOD&AMOUNT 2,Monitoring r ft. a1 Q � t. p
Injection Well: 'Recovery ft. R. Cv+:`o 1 o J c d•�-�,I A,Aig
•Aquifer Recharge QGroundwater Remediation ft. ft.
Nli Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(if applicttbleL ,
IIIInAquifer Test moot TO MATERIALEMPLACEMENT METHOD
Stormwater Drainage 0. g•
•Experimental Technology OSubsidence Control ft. ft.
•Geothermal(Closed Loop) OTracer _
20.DRILLING LOG(attach additional sheets if ..m_ arv)
a Geothermal Latin-Coolie!Return) 1111 Other a ,lain under#21 Remarks) FROM TO
DESCRIPTION(color hardness,solurock t rain size,etc.)
ft' 0 Qe Q► C1o.v
4.Date Well(s)Completed: (�'a Well Il)# Q }
5a.Well Location: lleni a 11 i. D C�'
Ci2, �„
Sbcvc Sc �- `a.bS ft• R\�� b Tian i e
Facility Name Facility ID#(if applicable) R g
Sao . J\ V t ( V 1`or7S td a-IOSa ft ft. _
�N)0AnN)k Cole
Physical Address,City,and Zip
rt. R.
S�0 K k 2f.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field,one lat/long is sufficient) —
J O��.t S 6 1 $�s ly 22.Certification:�3O`"10' ll • 6184'' w
6.Is(are)the well(s) permanent or Temporary `(5�1` + v 5 i.
Signature of Certified Well Contractor" Date
Yes orNo By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
f
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has!!been provided to the well own QWe!!Construction Standards and that a
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page :o 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:
9.Total well depth below land surface: a bs SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifdyjerent(exmnp(e-3(a�z00 and 2@ioO) (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of easing; LA 0
(ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"
6 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: QL3 eat y rl1 f above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) 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) 5Q Method of test:
Ci>,teh*T,+r'e 24c.For Water Supply& infection Wells: In addition to sending the form to
136.Disinfectiontype: U t, the address(es) above, also submit one copy of this form within 30 days of
firm 1b A Amount: I,6 U'Z• completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016