GW1--04744_Well Construction - GW1_20240812

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: La......7---
1.Well Contractor Information: I
Gary Thompson 14.WATER ZONES '
Well Contractor Name FROM TO DESCRIPTION
4418-A 60 11' e S ft' F't'sr.e i ea t' Is Pp4
NC Well Contractor Certification Number ft. @•
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased_wells)OR LINER(if ap 'Whit)
FROM TO DIAMETER. THICKNESS MATERIAL
Company Name C ft, I .30 ft. I 6 tr g in. I SDR 7.% PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: ac'a 1-1 0 Q"J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UiC.County.State.Variance.etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
A (cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DMunicipal/Public ft. ft. in.
®Geothermal(Heating/Cooling Supply) OResidential Watcr Supply(single)
ft. l ft. in.
El Industrial/Commercial DRcsidcntial Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: U ft. a t ft. $tniOE 'V
DIMonitoring QRccovcry ft. ft. �O+i,1S i'CVf I Hy�tq��
Injection Well:
Aquifer Recharge Groundwater Remediation ft. ft.
Aquifer Storage and Recovery19.SAND/GRAVEL PACK(If applte tble)
Salinity Barrier FROM TO MATERIAI. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control it, ft.Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.herdn.m.soilirock type,grate�,ete4
4.Date Well(s)Completed: 1'01� p't� Well lD# ® ft. PLACEMENT
d 1 1 A
1 16 nano/ Zocky Sots
Sa.Well Location: .as ft. 310 n g i k e 6-r e.r6 4 e
Sato P'iocytan Custom `l lome5 3 0 ft. ft Sii gi,Ile (r s ac n t t
Facility/Owner Name Facility ID#(if applicable) ft.
Im65 Rucoi tioAi-Iite,crnanio'n Za Ka1cm►i Ha\1 WC- ft. 2Lis' ft. ,jt�:..:
Physical Address,City,and Zip g1Oys ft. ft.
Fofs.ith 69a6"196 i(0 21.REMARKS ! 2624
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t
(if well field,one lat/long is sufficient)
y .a i `� 22.Certification:
6 0 i
N So° 1Si 1-4i•1 .$ W
6.Is(are)the well(s)(►,.(iPermanent or OTemporary Si o C cd Wct)tC.lintractar pate
By signing this form,1 hereby certif that the well(s)was(were)conslriwied in accordance
7.Is this a repair to an existing well: ®Yes or )No with ISA NCAC 02C.0100 or ISA NCAC 02C 0200 Well Construction Standards and that a
If this is a repair,fell nut known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under#21 retnarkc section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page ro grrovide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Q
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: OM a N S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2(d11009
�+
construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
If wafer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: tt (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: �b TAP �i d 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,
pp PIy� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 9. Method of test:retie k * "ie 24c. For Water Supply &injection Wells: In addition to sending the form to
�pT /o the address(es) above, also submit one copy of this form within 30 days of
i1
13b.Disinfection type: 1 t10° Amount: tiP 01. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revise 2-22-201 6