GW1-2021-07357_Well Construction - GW1_20210921

y�
Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I
1.Well Contractor Information:
t
Cameron BaZin 14.WATER ZONES:
Well Contractor Name FROM TO DESCRIPTION
4518-A Zoo ft' 74S. ft 8&0^
SEP 21 2021 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mul6tased(wells OR LINER rf a livable
Aqua Drill, Inc. Proce�s�ng unit FROM TO DIAME45;TER THICKNESS MATERIAL
Company Name 20211015
-- R
e ft. '$
fL in.
�o Z I O 16.INNER'CASING OR TUBING e6thermal:closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fl.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 13Mumicipal/Public ft. ft. in.'
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. 4` s ^0'
Monitoring Recovery ft. ft.
Injection 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 [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach,additional sheets if necessary)
Geothermal(Heatin Coolin Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,wiVrock type,grain s' etc
%
4.Date Well(s)Completed: Z( Well ID# SS ft. 6$ ft.
5a.Well Location: ft. ft.
ft. ft.
�OVy L �G1D�Facility/016r Name Facility ID#(if applicable) ft. rr.
V•t eAoia� ho Zrgr ft. ft.
Physical Address,City,and Zip ft. ft.
n_ `5 yI 21.REMARKS '
County 7 r h 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:
!261 14140 N 47 W illy Z-- — "
6.Is(are)the wells Permanent or Temporary Signa 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: E]Yes or
�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 informatio 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 I 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: 3 (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@1001 construction to the following:
10.Static water level below top of casing: SO (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 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: 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 C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: N 24c.For Water Suably&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: completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016