GW1-2021-06172_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZin WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A ao h• ?� ft.
e. fa
NC Well Contractor Certification Number 15.OUTER CASING for mutti cased•ivells OR LINER'if a Hcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
G
Company Name
@. 3 S ft in.
q I6ANNER CASING'OR:TUBING eothermall:'closed-loop)
2.Well Construction Permit#: J3�� FROM TO DIAMETER I THICKNESS T 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 [3Municipal/Public [t, ft, in.'
:.,)Geothermal(Heating/Cooling Supply) Pesidential Water Supply(single) g It.
lndustrial/Commercial [IResidential Water Supply(shared)
18:GROUT
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: h• za ft. i S m
Monitoring E3Recovery ft. ft.
Injection Well:
Aquifer Recharge [3Grotmdwater Remediation f L
19 SAND/GRAVEL PACK'if a livable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heatin Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,sofilmek Cain size,etc.)
© ft. (S ft 5080%
4.Date Well(s)Completed: 24 Well ID# 4S n• 93Cr ' r'
5a.Well Location: ` ft ft
Lldl Sw Y 5•t"O�d.•�. ft. ft
Facility/Owner Naam i Facility ID#(if applicable) ft. ft.
A'r1l ak, A���{I��w Ale.- ft. ft
Physical Address,City,and Zip ft. ft
S re XeS 21.rREMARKS
County Parcel Identification No.(PIN) iDSOTClt3 i011 CUOIi
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36.w;$s N $49,3;*06 W 1 2-1
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)-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 information Ind 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:
S.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: ? s 00 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@I00) construction to the following:
10.Static water level below top of casing: 549 (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: fD (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 , 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: /I.. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ZS Method of test: �!t~rLK� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�T the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 4• • Amount: GB�.— 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