GW1-2021-06779_Well Construction - GW1_20210809

�Pfint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZirl 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A Too ft.
NC Well Contractor Certification Number 15 OUTER.CASING for:multi casedFwells OR LINER if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ey I ft. in.
Company Name W40, L �b '3' 16-INNER CASING ORITUBING eothermal closed-loop)
2.Well Construction Permit#:
`' �� 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
lndustrial/Commercial BResidential Water Supply(shared) 19.GROUT
Ilrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O it 22— ft• e&Y1, + t
Monitoring DRecovery ft. ft
Injection Well: ft it
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK'if a licable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necess
FROM TO DESCRIPTION color,hardness,soilfrock `ain size,etc.
Geothermal(Heatin Coolin Return) •Other(explain under#21 Remarks)
/ 0 ft. 31
ft �d
4.Date Well(s)Completed: yl Well ID# 3( ft' loo S ft' p,B J,r4
5a.Well Location: ft a `�
y-cA.L ot,, ft. ft d
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�7o Pr 16Y" �ov� ��✓" �L� P'IvG ft. ft AvI Inil
Physical Address,City,and Zip ft. ft. a (OoeS
7Gtffry. 21.'REMARKS ' r�{;•e>rt qQ.,t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Field,one latt/long is sufficient) 22.Certification:
3,` �3Glio` N i9e�, S35oG' M,
f �- 7 21l2
6.Is(are)the well( Permanent or Temporary Signatufe of Certified Well Contractor Date
;0 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: [3Yes or
No with!SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informatio and 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: (O O M-) 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@100D construction to the following:
10.Static water level below top of casing: W/o (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: CJ (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: Tar/ 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: J 24c.For Water Supply&lniectio'n Wells: In addition to sending the form to
�j / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14-r n Amount: �b� 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