GW1-2021-05554_Well Construction - GW1_20211013

,�_t:•:P:,rint Form
WELL CONSTRUCTION RECORD(GW4An For Internal Use Only:
1.Well Contractor Informations
^
Cameron Bazin ��' `O�� 14.WATER ZONES
Well Contractor Name of FROM TO DESCRIMON
4518-A \,\ Cope �o�9 roe rt. S rt. 3 o"
3`D CJPG ft. ft.
NC Well Contractor Certification Number �`3�� R
\Ct � � 15.OUTER CASING for multi-cased wells OR LINER. if a Ilcable
Aqua Drill, Inc. FROM To DIAMETER THCKNESS MATERIAL
O ft. 3 0 ft.
Company Name
r - 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: A`wL-- !e�AQ t O L" FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): h• % in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) PtResidential Water Supply(single) fL ft.
:)Industrial/Commercial Residential Water Supply(shared)
IS.GROUT
)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft' 2l IL hi S pN�e�
Monitoring Recovery ft. ft.
Injection Well: ft ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ir.e' livable
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Mother(explain under#21 Remarks) FROM I TO DESCRIPTION color,hardness willmk type,prain size,etc
(O ft. /� % [r
�y, M
4.Date Well(s)Completed: T 2 Z( Well EM ft. ILLS ft.
5a.Well Location: R• ft.
Facility/Owner Name IC Facility ID#(if applicable) ft. ft.
S !* a eb OW4A/ /frT L ft. ft.
Physical Address,City,and zip ft. fL
Samy 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:
36. 28tn io N $o. V 5177- W
6.Is(are)the well(s)IdPermanent or Temporary Signature of Certified 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: 13Yes or No 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 dnd 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: (fL) 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@100D construction to the following:
10.Static water level below top of casing: So (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4!� (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: fo-C4a r above,also submit one copy of this form within 30 days of completion of well
Y 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) Method of test: 24c.For Water Supply&Iniecti�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: / Amount: O Z 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', Revised 2-22-2016,-�