GW1--04002_Well Construction - GW1_20240708

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 160 ft' i 6ti fL Pram;Vc c 4, 6?to
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased hells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 15 ft- bi k in. SOR a1 l PN c
Company Name
(,,l 16.INNER CASING OR TUBING(geothermal closed-loop)
l_
2.Well Construction Permit#: IiJP a O©el FROM TO DIASIE'TEli THICKNESS MATERIAL
List all applicable well construction permits(i.e. WC,County State. Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) iesidential Water Supply(single) R. ft. in.
Industrial,/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. ao ft. 82L„oPs\"e poV: 4, ,k .5 d rch$v•Q
0Monitonng DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
Aquifer Storage and Recovery D SalinityBarrier 19.S.AND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
0ExperimentalTechnology Lj Subsidence Control ft. ft.
DGeothemial(Closed Loop) nTracer 20.DRILLING LOG(attach additional sheets If necessary)
FROM TO DESCRIPTION(004.1
color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/CoolingReturn)Return) iOther(explain under#21 Remarks) 0 ft. ib ft. �C a L1a V
t
4.Date Wells)Completed: 6-ah'a14 Wcll iD# 10 ft- --to "- Scvn d rock,
5a.Well Location: J p 10 rt. 1 C ft. %\fie �-fix f'1\kt'
C101io„ \�C71Mt'S f� helaS'�)+1te is ft. ft. WC L(G.Vi\\-e
Facility/Owner Name Facility ID#(if applicable) ft• ft. u \{
i` Li'i�4 y EL. .:
3S6 SoneS Chapel Rd Roux );\le t.R. 4"13ao ft. ft.
Physical Address.City,and Zip ft. ft. J8
?!
KOCi In9l ari1 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:
36°.a,a1`` ' N --jai"'-kb 41,6 ,
W 6-36-au
6.Is(are)the well(s))iIPermanent or Temporary Signature of Certified e I cS Date
Br signing this.form, I hereby cerri/i'thet the nwO(s)was(Were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or NiNo with 15A.NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this isa repair,lilt out known is'l1 construction infbrntation and explain the nature 0-the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back 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 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 c:ttach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 S (ft-) 24a. For All Wells: Submit his form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3(cu200•and 2(ctt100') construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
If muter level is above casing use"+" 1617 Mail Service Canter,Raleigh,NC 27699-1617
11.Borehole diameter: & (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
pp above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: .o tow-1 A\( construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 Q
13a.Yield(gpm) t� Method of test:C'k '1t ljfwV4 24c. For Water Supply & iniectian Wells: in addition to sending the form to
�3 the address(es) above, also submit one copy of this form within 30 days of
ft
13b.Disinfection type: f a'O'to Amount: 16 oZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016