GW1-2021-06259_Well Construction - GW1_20211123

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A ` 6W. 42-S
ft. ft
NC Well Contractor Certification Number r 15.OUTER CASING for mullitased wells OR LINER if a iicable
Aqua Drill, Inc. FROM To DIAIviETER THICKNEss MATERIAL
0 ft. 7'0 ft , in.
Company Name
"16 INNER CASING OR:TUBING' edthermal closed-loop)r
2.Well Construction Permit#: *O 2 8 Og 2*17 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): fr. ft In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®I Municipal/Pubhc fr. tL in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.'GROUT: .
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: eO ft. /f ft
Monitoring Recovery ft ft. IF
Injection Weil:
fr. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK its "licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainage fr. ft
Experimental Technology Subsidence Control fr. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,soiltrock a in size,etc
/,' ,O fr. ft
4.Date Well(s)Completed: Well ID# ft. Y25 ft
5a.Well Location: ft. ft
`&fay Cos My% ft f.
Facility/Owner Name Facility ID#(if applicable) fr. ft _ '
o 4 6B f n a1 Aftkl 4,4_,Je=s.Q&.ZA4- f. ft.
Physical Address,City,and Zip ft fL
Yu tt�1 2L REMARKS UUS t`JCt,t fin t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36t 0110' N $O, 86+01 W f��
6.Is(are)the well(s)�IPermanent or Temporary Signature of Certified Well Contractor Date
��" aka 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 ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
/fthis is q,{e r_fill out known well construction information nd 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: t L1 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7-� (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,
If water 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
�1� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �O 4"Gf/r 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: 9G� 24c.For Water Supply&Injection 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: RrY Amount: 1,4.0 z- 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