GW1-2021-07069_Well Construction - GW1_20211129

�s�.P:,,rint Form `�1
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 too , Izis ft. V �T
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. (+ s ft. in.
Company Name
16.INNER CASING OR TUB G eothermal closed-loop)
2.Well Construction Permit#: 0�" 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 SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft. is
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft - tt. Co.vleF? �yG
Monitoring DRecovery ft. ft.
Injection Well:
ft.
Aquifer Recharge 13Groundwater Remediation
19.'SANDIGRAVEL PACK?if:a""licible
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fa
J Experimental Technology [3Subsidepce Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessaryy
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soilfrock a rain size,eta
� ft. tQ ft. Sw�
4.Date Well(s)Completed: !a Z''/�',,��yy�� )Well ID# (D ft, 2y S fL f
5a.Well Location: ft. ft.
r�l ft. ft.
Facility/Ow er Name Facility ID#(if applicable) ft. ft.
�/ 601 hI►--6 ft. ft. l
Physical Address,City,and Zip ft It. NOV 2
21.-REM4RKS
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:
6.Is(are)the well(s) Permanent or Temporary Signa ofCe�Well Co tractor Date
40 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 0I No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner. -
repair under#11 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: 2 w 5 (it-) 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@100) construction to the following:
10.Static water level below top of casing: S� (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
l' above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �C�O�/ 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
13s.Yield(gpm) `4 Method of test: f�V 1A&kA_ 24c.For Water Supply&Infection 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: O 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