GW1-2021-00477_Well Construction - GW1_20211222

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZin 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name
4518-A
Z Ze ft fL
ft. ft
NC Well Contractor Certification Number
15:'.5UTERCASING°tormulh-cased4ells-ORh�IER
Aqua Drill, Inc. FROM To DIAMETER THICKINESS MATERIAL
ft. d ft. in.
Company Name ^ n I
J.{4/ jV( s ( 16rINNERCASING:ORTQBING 'eothermsl+etosed-loo '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits f.e.UIC,County,State,variance,etc.) it. IL I
3.Well Use(check well use): It. ft. in
Water Supply Well: FROM REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipat/Public ft. % in.
Geothermal(Heating/Cooling Supply) JaResidential Water Supply(single) fL &
Industnal/Commercial 40'—Residential Water Supply(shared) i81:GRUiJT .
ft. fL
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O 73 t r f
ZbwoA-
Monitoring DRecovery ft. ft
Injection Well: ft. %
'Aquifer Recharge 00roundwater Remediation
SAND/GRAVEL'YACIE rf.a"livable `
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
_i Aquifer Test OStormwaterDrainage ft. ft.
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) OTracer 20.DRILLINGLOG attach:additional sbeets'af necessary)
Geothermal(Heating/Cooling Return) nOther lain under#21 Remarks FROM To DESCRIPTION color,hardness,soiurock rain size,ete
IL 56 ft sa
4.Date Well(s)Completed: fa 13 ZL Well ID# It. 3pS ft' i
ft. ft
Sa.Well Location:
�M 11 ft fL
Facility/Owner Name Facility ID#(if applicable)
irA h 64 Rill EmAr p j A?n [t. fL
Physical ddress,City,and Zip ft. %
( 21.REMARKS ..
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: r�
3 / 5726 N 'VD• �O 7S� W
6.Is(are)the well(s)J0Permanent or 13Temporary SigftMm of Certified Wellrontractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well• EYes ..r _t Nc with 15A MCA 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio and 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:
S.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: �t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J� (f>) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3Q2000''and 2@100) construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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: f 6 retry 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) Method of test: �6` � 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: !T Amount: n�Z completion of well construction to'tbe 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