GW1-2021-06256_Well Construction - GW1_20211123

Rant Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
100 h. 0 ft
4518-A cT
ft. ft
NC Well Contractor Certification Number 15.-OUTER'CASING for`multi cased:;wells OR LINER'if a Gcable-
Aqua Drill, Inc. FRO TO DIAIx7ETER THICKNEss MATERIAL.
ft. fL in.
Company Name Q u
P��� 20 2 0 t p Q 1 ''16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MAT MAL
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.
17.sSCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
IndustriaUCommercial Residential Water Supply(shared) 7T8..GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1"Geothermal
on-Water Supply Well: ft. 5 ft. ' s u tv�
Monitoring Recovery ft. ft.
jection Well:
ft, ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if.a "licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLINGLOG attach additionafsheets ifnecess(Heatin Coolin Return) nOther(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soil/rack type,grain size,etc
O ft. O ft
4.Date Well(s)Completed: IZIV2( Well ID# 0 ft. fL
5a.Well Location: ft. ft.
[.-0,6T MOSGs ft. ft
Facility/Owner game Facility ID#(if applicable)
ft. ft l ' 1`s GVt'
1 l S o rl ok c,.ay a./oY /f 011 g &G h. M
Physical Address,City,and Zip IF ft. fL
21.REMARKS
County Parcel Identification No.(PIN) li!7i'R !0NI PROCESS!NG UN I i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36 , 315 Y y N gIP5�r�3 W ��- �" ! Y
6.Is(are)the wells Permanent or Temporary Signature of Certified Well Contractor Date
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 ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informatiln and explain the nature ofthe copy ofthis 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: (O 10 (R-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: .4-0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"A 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (►n.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
�O�A fl, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y 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) Method of test: ow,kder 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: /�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