GW1-2021-06178_Well Construction - GW1_20211025

71 rm .
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only: •
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Wei I Contractor Name FROM TO DESCRIPTION
S 4518-A ft. ?" ft.
ft. ft
NC Well Contractor Certification Number I5.OUTER CASING for multi cased wells OR LINER ifa ticable
Aqua Drill, Inc. FROM TO DIAMETER THICIcxEss nIATRRIAt.
0 ft, v ft.
Company Name v
�� A O'�� :16.INNER CASING OR TUBING aothertnal closed-loop)-
2.Well Construction Permit#: !i 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: SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial EResidential Water Supply(shared) .18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2-7
tt f t CA.
Monitoring pRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge 13Groundwater Remediation
19:SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft, ft
Experimental Technology D Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sofll ck type rain size,etc.
o ft. is ft 4a1*1
4.Date Well(s)Completed: 0_/q, "`Y Well EN ft. 2,960 ft 61r."AFL
ft. ft
5a.Well Location:
V1/1 tl ��ri�fl�i�� ft. ft
Facility/Owner Name Facility tD#(if applicable) ft. ft
116o w Qv.1sorn All R� PJot-Amt ft
Physical Address,City,and Zip ft. ft. t' Processing Ull"
Sti(`l' 21.REMARKS
County ff Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latt/long is sufficient) 0p 1 22.Certification:
3j. 1$6g N O0.S�N�� W -
6.Is(are)the wells) Permanent or Temporary Signatu of Certified Well Contractor Date
r/- 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: ®Yes or No 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 informatio 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: (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@I00) construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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
�o fir above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) -0 Method of test: ow ke V 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: l�, '�+ Amount: 1(/O Z completion of well construction tot 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