GW1-2021-07063_Well Construction - GW1_20211129

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
30o ft. v 2 S tL ;
fL rL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER ifa !cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. c It. in.
Company Name
// 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 5 b 2- FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Slate,Variance,etc.) ft. ft. io.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
m IndustriaUComercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 214
Monitoring 13Recovery
Injection Weil: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19 SAND/GRAVEL PACK`if:a licable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. tL
Experimental Technology Subsidence Control ft. IL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach:additional sheets if necessary)
Geothermal(Heating/Cooling Retum) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc
C O ft. ft. 5A194
4.Date Well(s)Completed: ZS Well ID# k- ft Outtr
5a.Well Location: ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
W62 S 1�:fieAISti:10 a G+�r�o•^tyn�&C ft. fL
Physical Address,City,and Zip ft, ft. ,
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
36. 2G80., N 233Y$ W
6.Is(are)the well(s)ePermanent 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 o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
/f this is a repair,fill out(mown well construction informatio 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 fo -- -
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: q c SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000'C'and 2@100) construction to the following:
10.Static water level below top of casing: 70 (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 lniection 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: no-Vo►(1/ 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• �K�btQ 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: Amount: 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
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