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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