GW1--05831_Well Construction - GW1_20241001

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 n. 165 ft. FccAc koc 6 &P M
NC Well Contractor Certification Number a t?Q ft a65 ft r t�C' Q 5 !P
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIALA
Q ft. SS ft. 6114 in. Sbe at Pit Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 36;S 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. 1
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 12 Residential Water Supply(single) ft. ft. in.
IndustriaUCommercial DResidential Water Supply(shared) l&GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft. �x sta ft- 115 tof a fb.,fed+ HydrAAEd
Monitoring DRccovcry ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) fOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUrock type grain s ze etc.)
Q ft. Ia ft• REA. C ic.y
4.Date Well(s)Completed: et'y't�.y Well ID# la. ft. $Q ft. Saf lay RoclGy Sol 1
5a.Well Location: [ae) ft. p e ft. p i Ot, `_can i ie
Clayton Itome% oC M04 ir"y 8s ft. 305 ft. glue (GrrAn'to
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ft. ft. '
I`I Sa W i Son d Pi lob Mountain NC Al 041
Physical Address.City,and Zip ft. ft.
SAo CCS 21.REMARKS
County Parcel Identification No.(PIN) Irk,:it-,;.
1:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatilong is sufficient) 22.Certification:
v:.° as' 43.3 N so. a6' aa.sA' W V
6.Is(are)the well(s)]2tPermanent or Temporary Signa offer�tcd Well Contact, Date
By signing this form,i hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or DgNo with I5A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.Jill out known well constriction information and explain the stature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: OS (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2(0100') construction to the following:
10.Static water level below top of casing: SO (ft.) Division of Water Resources,Information Processing Unit,
If roarer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
L) y Air
f above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: RQ aC 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) 10 Method of test: Cejsjeh clIfne 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: I4T'1 -70°A Amount: I6 O a. 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