GW1-2021-06171_Well Construction - GW1_20211025

Pr..int Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
G
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
k. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi{a9ed wells OR LINER if a livable
Aqua Drill, Inc. FROM TO D TER THICKNESS MATERIAL
ft. y2 ft in.
Company Name
331 16. R CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: � FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits f.e.UIC,County,State,Variance,etc.) ft. It.
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) Residential Water Supply(single) ft. ft
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
n Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. Z( ft
Monitoring DRecovery ft. ft.
Injection Well: ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a 'liciible
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft
Experimental Technology Subsidence Control ft. ft
1 Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ElOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack type,grain size,etc.
0 fL rL
4.Date Well(s)Completed: 1 �S Zj Well ID# O k. Cs ft Ara ►!�
5a.Well Location: k- ft
Soh � ft. tt
Facility/Owner Name Facility ID#(if applicable)
ft. ft
24 S/o A tk ft. rt
Physical Address,City,
ity,and Zip k. ft O C
Ito kw� 21.REMARKS
County Parcel Identification No.(PIN) ��3ti011 v 'loll
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattloong is sufficient) p 22.Certification:0. 27 S t1 S N J O .O 7 3 S ap W �/1�• �- A0 ,Z
6.Is(are)the wells) _Permanent 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 JoNo with 15A NCAC 02C.0100 or ISA 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: 3o5 -(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 2@100D construction to the following:
10.Static water level below top of casing: (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: r-0 ft'/lt(l/ 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) 3 Method of test: a 24c.For Water Supply&Injection Wells: In addition to sending the form to
P the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 1�.oZ 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