GW1--04003_Well Construction - GW1_20240708

WELL CONSTRUCTION RECORD (GW-1)
I For Internal Use Only:
I.Well Contractor Information:
Gary Thompson
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4418-A 1°S It. 110 n• F'r of c t u f 2 t&P m
NC Well Contractor Certification Number a 0C.. ft. a,Q ft.
Fr,..7„...tci. Sti G PH
Aqua Drill, Inc. IS.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM 1 TO I
DIAMETER ' THICKNESS ,MATERIAL
Company Name v ft. 1 S ft. 6 t tj in.
5 oR a t PV C
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: E kW a�1 O--008 (€
PROM TO DIAMETER 1 THICKNESS :MATERIAL
List all applicable ne(l construction permits(i.e.UIC,County.State. Variance.ete.l ft.
ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
OMunicipal/public ft. ft. in
Geothermal(Hcating/Cooling Supply) Residential Water Supply(single)
Industrial/Commercial ff. i fl. I m.
Residential Water Supply(shared) _
Irrigation18,GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. ft. l'12n�art tt
a t� s Po�r • ►A 1
Monitoring 0 Recovery d t a�!
injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation rt. ft.
Aquifer Storage and Recovery OSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAI, EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control
ft. rt.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach addition al:eets:::::::isary)
Geothermal(Heating/Cooling Return) Other(explain under#21FROM TO DESCRIPTION(cness soil rock him grain si c,etc.)
p Remarks}
O ft. J3 ft. fe 4.Date Well(s)Completed: 1 '\-au Well ID# 1 3 ft. .-1 ft.
S0.0a hock.
5a.Well Location: 1• ft. --lib ft.
(to,/ton domes* oC RziAsv ile -745 ft. 9.4i S ft.
Facility/Owner Name zlve ITrov-1 i t c
Facility ID#(if applicable) ?1 ft. ft.
'V11 C.oU'(A1 Li In< IZ A Kc't A N'i l%e N C. f��,lasd ft. R �.�1.-.- aE i
Physical Address.City,and Zip ft. ft. I
hoc k;n h�►r� 21.REMARKS
County Parcel identification No.(PIN) '1r.3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Lrt
(if well field,one fat/long is sufficient)
22.Certification:
II
3(° lb' ' ss N -no Ja` 5a,•t--1` W
1- i-a 4
6.Is(are)the well(s)PiPermanent or DTemporary Sig tore o Ccrtificd etor Date
By signing this form,1 hereby certi$that the rre//(s)was(were)constnaied in accordance
7.Is this a repair to an existing well: rjYes or IZNo with 15A NCAC 02C 0100 or 15A NCAC 02C 0200 Well Cansintction Standards and that a
If this is a repair,fill out known well construction information anti explain the nature 011ie copy of this record has been provided to the well owner
repair under#21 remarks section or on the hack of this flow,
23.Site diagram or additional well details:
8.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 attach additional pages if necessary.
drilled: _
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a4S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30.4200'and 2(a;100')
constmction to the following:
10.Static water level below top of casing: 440 (ft.) Division of Water Resources,Information Processing Unit,
1(nater level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method k�kt�fNt (\i r above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary, construction to the following:
S cable,direct push.etc.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method of test: C.MG:1'14'Tir+R 24c.For Water Supply &injection Wells: In addition to sending the form to
s� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: H t 1 0 o Amount: 1 b Get completion of well construction to the county health department of the county
where constructed.
Form G W-I North Carolina Department of Environmental Quality-Dis rsion of Water Resources Ret ised 2-22-2016