GW1--04821_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
Gary Thompson 14.WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
4418-A go s ft. f y C") ft. 314 6.04 F.1•N 0,c
It. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THtIIC�KNESSi MATERIAL
0
ft. i 0 Q ft. b'14 in. sit* ..).1, Pv C
Company Name r�1 Q t� L /� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: L Hw} a�wr`)•3 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 -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) CaResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. as ft. 6en On. 5,o,1r + laydro.ie
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.soiUrnck type,grain sire,etc.)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
6-al
ft. q ft. ze AUta i
4.Date Well(s)Completed: 6-al-ay Well iD# q ft. ei5 ft. 50%rig),.1 So i I
5a.Well Location: -1S ft. %et° ft. D 1%Pt 6(ari►4 e
C1Aytctr% kkomes pF Ze,a IBC too ft' SOS ft. )y'lVe. brchr ie
Facility'OwnerName Facility 1D#(if applicable) ft. ft.
31l) &nose Rd �jo\(eSaQ. e A.\' 1C di"13S 1 ft. ft.
ft. ft.
Physical Address,City,and Zip
21.REMARKS
f SGki naJlfticok>M
County Parcel Identification No (PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1 G ?OP i
(if well field,one lat/long is sufficient) 22.Certification:
16 a
° 1°1 1b. ' t
N rt°t"5°I a.c, W
_ b-a1-aw
6.Is(are)the well(s)13Permanent or OTemporary Sig to of Certified W I Contractor Date
By.signing this form, I hereby certifi'that the well(sl was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or 0No with 15A NCAC 02C 010(I or 15A NCAC 02C.0200 Well Construction Standards and that a
'Phis is a repair.fill out known well construction btfbrntation and explain the nature nl'the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this Dorm.
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: 5 OS (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths if different(example-3(a?.200'and AMMO') 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
11.Borehole diameter: & (in.) 24b. For injection Wells: In addi'don 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: goAar t Air 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) '3/41 Method of test: Covkil *4 j e 24c. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: I$u iii 10 IP Amount: 16 G/. 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