GW1-2021-06771_Well Construction - GW1_20210809

�Print �orrn
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 9itl� ft' o o e. 9.0 &PI1I
e. rL
NC Well Contractor Certification Number 15.OUTEWCASING for multi cased-wells OR LINER if a Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICIINEss MATERIAL
ffi C, ft.
Company Name
16cINNER CASING OR TUBING eothermal closed400'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERLIL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft In.
3.Well Use(check well use): h' ft. in.
W er Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.:GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2t ft. G i 3 n ,f
Monitoring Recovery W I
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19 SAND/GRAVEL-PACK'if a liceble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,willrock type,grain size,eta
40 ft. Se, ft. �p
4.Date Well(s)Completed: Well ID# ar k• 4 S ft.
5a.Well Location: S N �.,S ft. 4_r
S rz,uc �o b u ft. ft.
Facility/Owner Name Facility ID#(if applicable) h• ft. a,S
l 28o Fa.0 b-ay R2 f<r'��t�,!f'G 2 ;fit ft. ft. V-Ui w
Physical Address,City,and Zip
It. ft. 107
21.REMARKS V.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
3�1 �6�51 N W -
2 2
6.Is(are)the well(sermanent or Temporary Signature Wertified Well Contractor 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: ®Yes or JjNo with 15A NCAC 01C.0100 or 15A 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 copy ofthis 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
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: ' 60S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 1Q100D construction to the following:
10.Static water level below top of casing: 3 o- 00 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: 17 (in.) 24b.For Iniection 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: r(1t�"� W construction to the following: g
(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) Method of test: WAr"r 24c.For Water Supply&Iniection Wells:`In addition to sending the form to
� the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection type: IT Amount: 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