HomeMy WebLinkAboutGW1-2022-01675_Well Construction - GW1_20220128 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14:WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
O ft. y it.
O� fl_
4518-A "1
fL ft
NC Well Contractor Certification Number
Asp.:OUTER(CASING:for.mut6 cased whlls"ORZINER :a" bcable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. `7 0 ft. in.
Company Name
i- ;i16:INNER'CASINGORTUBING:`eothermahelofed loo _ -.:
2.Well Construction Permit#: i 6�� I 0 —��y FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.U C,County,State,Variance,etc) It. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SITS THICKNESS MATERIAL
Agricultural 3Municipat/Public ft. ft in.
Geothermal(Heating/Cooling Supply)PResidential Water Supply(single) ft. ft ,a
lndustrial/Commercial DResidential Water Supply(shared) 18:GROUT
[Aquifer
ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 0 ft. �-o ft. G'Ir e
itoring :Recovery ft. ft.
on Well:
ft. ft.
fer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK if.a.licable
fer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Test OStormwater Drainageft
rimental Technology OSubsidence Control ft ft•
hermal(Closed Loop) OTracer 20.DRILLING'LOG attach'additional:sheetsafneceFROM TO DESCRIPTION color hardness,sotUrock in etc.hermal(Heatiqgbqooling Return) Mother lain under#21 Remarks a ft. '30ft.
4.Date Well(s)Completed: /2 2-2—Well ID# 3 ft' ft
ft. ft.
5a.Well Location:
(�a k wood- ft. fL
Facility/Owner Name / Facility ID#(if applicable) ft. ft
ft. ft.
Physical Address,City,and Zip ft. ft.
2L REMARKS .` t..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
6.Is(are)the well( Permanent or OTemporary 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: E)Yes or 6-No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fell out brown well construction lnformad arid,
explain the native of the ropy 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
C i
9.Total well depth below land surface: qJ (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells I&I all depths if different(example-3Q200'and 2@100) construction to the following.
10.Static water level below top of casing: V d (ft•) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"'+/t 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: l/J (in.) 24b.For Injection 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
m 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 276994636
13a.Yield(gpm) 30 Method of test: 24c.For Water SuDDIv&Injection'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: �Y2Q 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