GW1-2021-00253_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
IPTI
Well Contractor Name FROM TO DESCR ON
4518-A ft. .3o S rt.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER ifa licable
Aqua Drill, Inc. FROM To D TER THICI4YEss MATERIAL
O ft. 50 ft. in.
Company Name 1 (035�� 16.INNER CASING OR TUBING eothermalclosea-loo
2.Well Construction Permit#: FROM To I 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 []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) VIResidential Water Supply(single) ft. ft. in.
'Industrial/Commercial Residential Water Supply(shared)
-18.GROUT
JNAquifer
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: ft. 2 eS41�O�rMonitoring Recovery ft. ft.jection Well: ft. ft.
Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C]Stormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary) -
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM T`O, DESCRIPTION color,hardness soiVmck rain size etc
'/ / � ft' Y Q it. Soi,vt�
4.Date Well(s)Completed:_1(L 1 21 Well ID# �O ft' 3oS
5a.Well Location: IT ft. ft.
11 �jt`� ft. ft.
Facility/Owner Name 'I Facility ID#(if applicable) ft• ft.
t S(S P,'1olr 4,osrc,dl r L Pt'1or MTN ft. ft.
Physical Address,City,and Zip ft. ft
Sto k" 21.REMARKS ZVI
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rf well field,one lat/lon sufficient
( g�is > p 22.Certification:
34• ` n I4 N OJ• YZn46 W
6.Is(are)the well(s),dPermanent or OTemporary Signature of Certified Well ConlEctor 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: [3Yes orNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd No
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 1 GW-I 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: O S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifti fferent(example-3@200'and 1@100D construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+I 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: fib/
�O\"(V above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.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) 56 Method of test: ayo^'t- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: i Amount -P 7, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016