GW1-2021-05915_Well Construction - GW1_20211025

�P;int�Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZin 14.WATER ZONES
FROM TO DESCRIPTION
Well Conductor Name a,rt. 38 C ft. n [,
4518-A GO v
k. f4
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THIcxNEss MATERIAL
ft. -f ft. / in.
Company Name / r�
u p, 116.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: 2 l Li O 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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) k
esidential Water Supply(single) rL ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
]Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 2-2—
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery [ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology [ISubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING:LOG.attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soitlr k e, rain size,etc.)
Geothermal(Heating/CoolingReturn) Mother(explain under#21 Remarks)
4.Date Wells)Completed: Well ID# ft. 8S ft iptol'dYi
Sa.Well Location: 1 k. ft.
UP ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
hitir lis ar !.✓►�St.--5�Izrt,/V rt. rL 2
Physical Address,City,and Zip ft. ft. GegS�
y�h� 21.REMARKS `n O
County r Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fie sufficient)
field,one lat/long is sucient) p 22.Certification: Q
3 1 14228 N g o,3`�'�Q°I' W / ?�
6.Is(are)the well(s) Permanent or Temporary Signam f CertifieTWell ContiVelor Date
�,f� 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 l�/i1No 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: 39S (ft-) 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@100) construction to the following:
10.Static water level below top of casing: 7,0 (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: (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: f O tG►(V 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) G.0 Method of test: 171nLk f_ 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: i1OZ 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