GW1-2021-05571_Well Construction - GW1_20211013

Form.
WELL CONSTRUCTION RECOJt1K9V1C=1 For Internal Use Only:
� -1.Well Contractor Information:
nr 1 � TO
Cameron Bazin `1` ���(tg��l 14.WATER ZONES
r)C�v FROM TO DESCRIPTION
Well Contractor Name F�tC^, �y t o^\,on
4518-A 1e��� 3puJ�5'v y p� 2
k. fL
NC Well Contractor Certification Number 15.OVIER CASING for maltl cased',wells OR LINER if a 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATRRiAr.
ft. 0 ft � ' in.
Company Name
'-I of 2`�23,ZeZ `16.INNER CASING OR TUBING'etithermal closed-lob
2.Well Construction Permit#: !�� 4 l FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. IL in.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) idential Water Supply(single) ft. ft. in. i
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
]rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. L41 ft. GPI
Monitoring DRecovery, k. k.
Injection Well:
k. ft.Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING:LOG:attach additional sheets if necessagy
Geothermal (Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soRtrock tyM grain size,etc
v k. 3� ft �Ibp
4.Date Well(s)Completed: �S Well ID# So ft. fL Ah�
5a.Well.Location: ft. ft
ft. ft.
te-r Rr�ti A-,joa•% G k. ft.
Facility/Owner�
m Maine n` !- Facility ID#(if applicable)
3M ,�'*(ani•1 12A yn,d 44 N�f, ry* 2�s ft. ft.
Physical Address,City,and Zip If ft. ft.
��l 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:
yo 9 N 80.?6 7/ W
6.Is(are)the well(S Permanent or Temporary Signature of Certified Well Contractor Date
�'�' A
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existingwell: [3Yes oNo with 15A NCAC 02C.0100 or 15A NCAG02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informattexplain the nature 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:
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 I 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: 0 (ft-) 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 1@1001 construction to the following:
10.Static water level below top of casing: too (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniectlon Wells: In addition to sending the form to the address in 24a
/O� V above,also submit one copy of this!form within 30 days of completion of well
12.Well construction method: t 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: i2tac,eC G 1 24c.For Water Supply&Iniection 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: 1,62 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