GW1-2021-05914_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM It n- ft.TO DESCRIPTION
,
4518-A �/
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
& ft. 60 fL in.
Company Name
3 �!'G/ INNER CASING OR TUBING eothermal dosed400
2.Well Construction Permit#: 7 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) R2esidential Water Supply(single) fL fL in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
-
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. N ft. t
,Monitoring 13Recovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if.a livable
Aquifer Storage and Recovery ®ISalinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Ttacer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) _Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,gnin size,etc
O ft. ft. 7
4.Date Well(s)Completed: Well ID# ISO
ft,
li�S ft. JVr*A'T v
5a.Well Location: ft. ft.
Scelq Mrrm'/lyh ft. ft
Facility/Owner Name f - Facility ID#(if applicable) ft. ft
A l i/l��/ rc-1 1IG ft. ft
Physical Address,City,and Zip fL ft
21.REMARKS (�
County Parcel Identification No.(PIN) U�
�pto �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: t W(if well field,one IaUlong is sufficient) ( 22.Certification �C'
D
35, OT3 N �o� / W k__ /�
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or J6No with 15A NCAC 02C.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 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 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: 2 Y� (th) 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@I00) construction to the following:
10.Static water level below top of casing: 5a (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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: �D ryR / 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) 2-40 Method of test:_ 24c.For Water Supply&Injection 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: 1 Amount: 11607- 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