GW1--04192_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
Gary Thompson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
160It• f6S ft. Fro,C+pr 1 \6Pfr
4418-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER _T THICKNESS MATERIAL.
Company Name 0 ft. i,S. ft. 6 7`j in. S Dry a\ P v C
p��P l 16.INNER CASING OR TUBING(geothermal closed-loop)
T
2.Well Construction Permit#: �„H W all.-(%0/ FROM TO DIAMETER _THICKNESS MATERIAL
List all applicable well construction permits(i.e. L'IC.County State, Variance.etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. n.
Water Supply Well: 17.SCREEN
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, in.
D Industrial,Commercial f Residential Water Supply(shared) 18.GROUT
Ilit-ligation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. a. ft. a2olo‘_ci i, poor ,t t'{NdfaiP.
[3Monitoring DRacovcry ft. ft.
Injection Well:
ft. ft.
0Aquifer Recharge Groundwater Remediation
—
19.SAND/GRAVEL PACK(if applicable)
0Aquifer Storage and Recovery 0Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology EtSubsitlence Control ft. ft.
[)Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under 021 Remarks)
0 ft. i , ft. .e d Ci a.y
4.Date Well(s)Completed: 1- - 4 LI Well ID# t I. ft. no ft. Sctla cc
c k
5a.Well Location: 1l0 ft. llS ft. Rlue &(O.n1Nf'
Clc' ton 1-ones 0( R.etAs\iA1le 115 ft. ass ft. Eive. 6(0,0'x ie
FacilityiOwncr Name Facility IDS(if applicable) ft. ft. ' i^!
tall p-1'tzpo5Y- OncC , RA fidSvlile ai ab ft. ft. .��. Jr��
Physical Address,City,and Zip ft. ft. J U L 1 7 ?'J?
Q i n�hcl(� 8'1 0.039,33149 21.REMARKS
County Parcel Identification No.(PIN) , .it.l,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lot/long is sufficient) 22.Certification:
beILI)S t, i ` N lgc31, Lt .5 W
Z -1©-ay
6.Is(are)the well(s)j li Permanent or DTemporary Signs tics of C rtihcd Well Date
Sr signing this/'arm, 1 hereby cerlifi'Mat the wear)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or tiNo with 15A NCAC 02C 0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair fill out known well construction information and explain the nature of the crept'of this record has been provided to the well owner
repair tinder#21 remarks section or on the back of this Juror.
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: aaS (ft.) 24a. For All Wells: Submit this; form within 30 days of completion of well
For multiple wells list all depths if different(example-30000'and 201)100') construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-±" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: h (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: lC77 O\G('-t IN.,f 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
13a.Yield(gpm) CO ep ) Method of test: (it'�Gh � i I M e 24c.For Water Supply& Injection Wells: In addition to sendingthe form to
NTH / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i1 f I7 'VC/0 Amount: /6 O Z. completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016