GW1--03294_Well Construction - GW1_20240603

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name
FROM TO DESCRIPTION
4418-A gs'` g 6 I=cn.clor \ &QM�
NC Well Contractor Certification Number I�U ft. 1 a a ft ra L' or '1g pPA
-\ CI?
15.OUTER CASING(for multi-cased wells)OR LINER(if ap liable)
Aqua Drill, Inc FROM TO DIAMETER_ THICKNESS MATERIAL
Company Name •
O ft. rg S ft. 61 I Li in._ SO1]1 i` I?.4 C
�� 16.INNER CASING OR TUBING(geothermal dosed-loop))
2.Well Construction Permit#: 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): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
DAgricultural 01Municipal/Public ft. ft. In.
OGeothermal(Heating/Cooling Supply) isaResidential Water Supply(single) ft. ft in,
olndustrial/Commercial Residential Water Supply(shared) 18.GROUT
Il Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. !1 fj ft' ' '` ie QOU',. a Hy eirc �e
0Monitoring Recovery ft, O� R.
Injection Well:
ft. ft.
Aquifer Recharge jGroundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
BAquifer Test OStormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft. R.
9Geothennal(Closed Loop) QTracer N.DRILLING LOG(attach additional sheets if necessary)
Geothermal eatin Coolie Return) fOthcr(explain under#21 Remarks) FROM TO DESCRIFI ION(color,hardness,soNrock type,grain size,etc.)
g/ g
o ft. la ft eecl cia.1 I t 'c k
4.Date Well(s)Completed: S-I R-I4 Well ID# ,a, L 0 R' S os,.y 1 o ek
5a.WellLocation: U ft . ft' s\ rcnfi ' e
Shane !'lonelley 3S ft- 1C�5 ft glo Irroun►te
Facility/Owner Name Facility ID#(if applicable) ft R-
IS60 P'1nPy ln
MoOtatn ' A \e,lcainv4 Lwe al( ft• R.
Physical Address,City,find Zip R. ft. --
V
a t O ic e$ 21.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) 22.Certification:
2 t
36`"ac I1:i" N t;;oc' ‘a' ‘ ..; a� W
1,, ?...6\fla_PF------
SignaS I S-a�i
6.Is(are)the well(s)t1Permanent or Temporary oreof Ce tll Cfor paw
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or NNo with 1SA NCAC 02C.0100 or ISA,VCAC 0.2C.0200 Well Construction Standards and that a
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 owner.
repair under#2/remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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
Q
9.Total well depth below land surface: ,US (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2©100)
construction to the following:
10.Static water level below top of easing: —10 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
b
II.Borehole diameter: p ii (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: O 1 fAW.y PO,C 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 40 Method of test: CO. .O` ,N"S`t T‘wYe 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ii TH I l0 v Amount: r b O 2 completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016