GW1-2021-05550_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: t. 9
Cameron Bazin C IC' 0 14.WATER ZONES
Well Contractor Name + FROM TO DESCRIPTION
4518-A C� 1 Uri�it. 32S
it. `
NC Well Contractor Certification Number tJ(rr�
3� C� C) 15.OUTER CASING for multicased wells OR LINER rf a livable
Aqua Drill, Inc. ;,��" o�y� FROMTT(5 DIAMETER THICKNEssMATEO ft L in.
Company Name v
3 ^ 16.I INNER CASING OR TUB NG eothermal-dosed-loo
2.Well Construction Permit#: J FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, fL 1
3.Well Use(check well use): ft• ft
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. t
2.ti f G�t Oc lGL
Monitoring DRecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVELPACK(if.Applicable)
'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage fa ft.
Experimental Technology 13Subsidence Control ft. ft
Geothermal(Closed Loop) ®ITracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Coohn Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack rain size,etc
Q ft. 20 ft
4.Date Well(s)Completed: 27 21 Well ID# ft -325 ft
5a.Well Location: /� ./. ft. ft.
5n^ ` e/�1G 1 /l G ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
ft. ft.
Physical Address,City,and Zip ft ft.
15 fo kC S 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
U. 33 Z f7 N 180, YdzZ.t W �_ z
6.Is(are)the well(s)P Permanent or 13Temporary Signature of Certified Well Contractor Date
....�1111 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: E3Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain the nature ofthe 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: 32 S 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: So (ft) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
(`O/��. 1, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: `- /r construction to the following:
(Le.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: �i�ke.0^ 24c.For Water Suooiv&Iniectio n.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: f+ 1 6! Amount: A;2 Z completion of well construction t!the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016