GW1-2021-02306_Well Construction - GW1_20210722

' � ,rint Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Cameron BaZln 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft.
4518-A 7� �z� rL
Ct. tL
NC Well Contractor Certification Number 15.OUTER CASING for mull-cased wells OR LOVER if a Usable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATCRIAr.
(_. ft. S� ft. G in.
Company Name 16.,INNER'CASING OR TUBING(geothermal dosed-loop)
2.Well-Construction Permit#: 4,15A G- 01Zo�4 -2oLt FROM TO 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL fL in.l
Industrial/Commercial Residential Water Supply(shared) 18:-GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well, p ft. 2 ft. �t' S Poc r4L or ld �i c1(Grl
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
f"SAquifer Recharge Groundwater Remediation
19:SAND/GRAVELPAGK ifApplicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology 1 Subsidence Control ft. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil rock type,gmin s etc
O ft. 710 ft- 4,0
4.Date Wells)Completed: 7 2 Z( Well ID# 20 ft' 9 ft. S �RoCk
5a.Well Location: ft' 725 ft.
'S"j"'q-j" L✓o7AT— ft. rL
Facility/Owner Name Facility ID#(if applicable) ft. ft.
2y2( {4:;nntn�3 R� �uS� 4Cn G1 /yG 27a�� k. rL
Physical Address,City,and Zip ft. f4 e9 21
2L REMARKS
County Parcel Identification No.(PIN) rr rta`"5
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one W/long is sufficient) 22.Certification:
31 ,h5 S 4 ,,��(( N go• y92�G W
6.Is(are)the well(s) Permanent or Temporary Signa' 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: ®Yes or InNo with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information nd explain 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 I 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: 72 S' (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(Qa 200'andd 2®100') construction to the following:
10.Static water level below top of casing: CO 0 (ft.) Division of Water Resources,Information Processing Unit,
]fwater level is above casing,use"++" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: k' (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
R.t-T above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.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: kzIr 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: (hlDrf n L Amount: 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