GW1-2021-00689_Well Construction - GW1_20211222

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
i
1.Well Contmetot Information:
Cameron Bazin x4i.wATER$OIVES
FROM TO DESCRIPTION
Well Contractor Name O ft, fL M
4518-A ft. rL
NC Well Contractor Certification Number 15:.OUTERiCASING for multi cased•:wells OR I TER a livable
Aqua Drill, Inc. FROM To DIAIIIETER - TMCKNESS MATERIAL
® ft. I IL 1 6
io.
Company Name 16:'1NNERr CASING
OR-TUBING: "eoth6rmaletosed400 _
2.Well Construction Permit#: FROM To DIAMETER THICK NEM MATERIAL
List all applicable well construction permits(r.e.UIC,County,SraM Varianca etc.) ft. ft In.
3.Well Use(check well use): ft, ft. in,
Water Supply Well: FROME TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
:)Agricultural E3Municipal/Public ft. ft. in.
: Geothermal(Heating/Cooling Supply) OlResIdential Water Supply(Single) fL fL in.
1ndustrial/Commercial DResidential Water Supply(shared) 18`.GROUT
[Aquifer
on FROM TO MATERIAL EMPLACEMEENTMETHOD&AMOUNT
ater Supply Well: `� ft' 24 ft' C�� Soring Recovery ft. M
n Well: fter Recharge Groundwater Remediation ::19.SAND/GRAVEL PACK if,a livableer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test OStormwater Drainage ft• fLimental Technology Subsidence Control % ft•
ermal(Closed Loop) [ITracer 20.-DRILLING'LUG attachadditional sbe@t§if necess.,; FROM TO DESCRIPTION color hardness,soillrock e, is etc.emi9l(Heatin Coolie Return) Other lain under#21 Remarks � ft, 30 ft0.7 �•
4.Date Well(s)Completed: l`41 not WeIL,ID#rn" '3� ft. S fL t5;�/qLr
5a.Well Location: ft. it
C�/ ft.
ft.
Facility/Owner ame Facility ID#(if applicable) ` ft• ft
fL
Physical Address,City,and Zip ft, fL
Y 1[.n., . 2L REMARKS. ;t c,`^ l F F:f, C r'
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
7' lv ic•y,�Q eft � Iy / -
6.Is(are)the wells) ermanent or Temporary Signature ofCertifie�tractor 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: 0Yes or _ No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatioleand 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 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 f0 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following.
10.Static water Ifv 00
ei below top of casing: YID (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: y (fn.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
�,w�V above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: `'^'/ 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) S Method of test: 1314 tJr' 24c.For Water SunDly&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: r Amount: Z.. 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