GW1--03475_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD GW-1 --�----__ Print Form
For Internal Use Only:
1.Well Contractor Information:
Gary Thompson
Well Contractor Namc 14•WATER ZONES
FROM TO DESCRIPTION
4418-A 6 ft
600' 1 co.r: cr 11y M
NC Well Contractor Certification Number ft. It.
Aqua Drill, Inc 15.OM OUTER CASING for multl•caued wells OR LINER if applical
FR TO DIAM127I THICKNESS
Company Name
O ft• 1 MATERIAL
R. 6\Yy in• TORa.k NC,2.Well Construction Permit#: J 1 d.-O i a 16.INNER CASING OR TUBING(Iothermal dosed-l000•0)
List all applicable well construction FROM TO DIAMETER THtCtPIFSS
permits(ie.UIC,County,State,Variance,etc.) ft. AfATERL►L
ft- is
3.Well Use(check well use):
ft• ft. io,
Water Supply Well: 17.SCREEN
Agricultural MunicipaUPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
It I Geothermal(Heating/CoolingSupply) tt. in.
PP y) Residential Water Supply(single) —
IIndustrial/Commercial tt• ft• la
Residential Water Supply(shared)
•Irri_letion IS.GROUT —
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
•'Monitoring IIIIII Recovery ____22. �(7 ft 'migiss
h �V rOV T t �1 alTia e,
Injection Well: ft• ft.
allAquifer Recharge QGroundwater Remediation ft. ft.
•Aquifer Storage and Recovery DSalinity Barrier 19 SAND/GRAVEL PACK i<a !feeble)
FROM TO M.4TEPIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage R ft.
•Experimental Technology OSubsidence Control —
ft. ft.
U Geothermal(Closed Loop) Tracer _
Geothermal 20.DRILLING LOG(attach additional sheets if ary)
te(HeatingCooling Return) f Oihcr(explain under#21 RcmariLc) P>RnM ro DESCRIt'1ION(ester,taranne eaiUroek t
IL
(I. ft. ype,gram else,etc)
mi 4.Date Well(s)Completed: S` Well ID# I S It• S Re�'�`'a'c
R. L
Sa.Well Location: 71ikn0 r O G
ft, ft,
Claud S 6 1,�►e lrro�t��.� C
rerNam s of (ire nS OcO 1�5 ft �I��ye bce►ntiR
Facility/Owner Name Facilit
y ID#(if applicable) ft. ft•
14`iM1 NG h bf, Re‘asvk\ke a-119.o ft. t.•
Physical Address,City,and Zip
R ocki f1y)Q,M �'1 n
ft. ft. a]�
.1 6600 q\vj9•�46 21.REMARKS — JUN 1 1 2624 County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I►1C+1):�aarta P•r'f`>A., rj Up,(if well field,one lat/long is sufficient) f><fihl'tl:aa
d 2 . V�++ 22.Certification:
D N d1 4 6' Sb.O'" w A 6.Is(are)the well(s)0permanent or Temporary D 1 g' 1 '�`'t
Signature of Cetified Well Cantrac Date
7.Is this a repair to an existing well: Yes or �Ly/yryNo By.sighing this form,I hereby certify that the well(s)was(were)constructed in accordance
[Phis is a repair,Jill out known well constructionniit formation and explain the nature of theP this with ISA NCAC 0/hasbeen
!SA NCAC 02C.0100 Well Construction Standards and that a
repair under#11 remarks section or on die back of thisJonn. provided to the well owner.
23.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Site diagram
the back this additional a e Itot providel additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells You maya g
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
1
For multiple wells list all depths if di erent(example-3 aS (fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
p C)1oo'mid l(o�100�
construction to the following:
10.Static water level below top of casing: 50
Ifwater level is above use (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: gefteAf l An r above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) i `i 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) I/y Method of test: ►A{G1►et 1'
` thSe 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type: 10 p/C the address(es) above, also submit one copy of this form within 30 days of
Amount: (& 0$ 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