GW1-2021-07601_Well Construction - GW1_20210903

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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 5W ft. 45 FL ' �
ft. rL i
NC Well Contractor Certification Number 15.'OUTER CASING for mu16 cased wells OR LINER dapplicable)
_
Aqua Drill, Inc. FROM TO DIAMETER TIHCKNEss MATERAL
ft. 3.L ft 6 in.
Company Name
Q 16.-INNER CASING OR:TUBING "eothertnal--closed-loo
2.Well Construction Permit#: S.7 S 4 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. % in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural ®IMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18-GROUT
In'1 ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- 3o rl 4i1n0t !L'li
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwatet Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ®ISalinity 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 (Heating/Cooling Return Other a lain under#21 Remarks FROM TO DESCRIPTION color,hardness,soilfrock type rains etc.
O ft. 10 ft. a.i►
4.Date Well(s)Completed:ishi ,` Well ID# ft.
�jps rt.
5a.Well Location: ft. ft.
I 144A% {p04sAy ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft
c' 21
177 Holt kd t jesrElc,�,A/!. Z7o$ ft. ft.
ft.
Physical Address,City,and Zip
S fbkaS 21.REMARKS Ge
County Parcel Identification No.(PIN) f1�0��3 Se10
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 G_ 417.Tor N $o, 177ta?- W Z-"/
6.Is(are)the well(sPermanent 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 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information a explain the nature ofthe 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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: co (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: 160 (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: 40 (in.) 24b.For lniection 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: f O rCt,r// 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) J Method of test: t"' 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:!Gn?� 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