GW1-2021-02800_Well Construction - GW1_20210805

.Print Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contactor Name FROM TO DESCRIPTION
4518-A rt. Z p� -ft. ,� �.�M
fL ft.
NC Well Contractor Certification Number
`35.OUTER CASING formdlti-cased wells OR LINER f a' Iicable
Aqua Drill, Inc. FROM To DIAMETER TIIICIavEss MATERIAL
6
16:INNER CASING ORTUBING. eo m
Company Name �
thermal closed-moo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale,Variance,etc) ft. fL In.
3.Well Use(check well use): ft. ft. in.
iTrri ation ater Supply Well: 17:SCREEN
FROM TO DIAMETER ZE SLOT SI THICKNESS MATERIAL,
Agricultural MunicipaL/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft fL
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
FROM TO MATERiALr EMPLACEMENT METHOD&AMOUNT
/ 1 1
Non-Water Supply Well: O ft' 2 ft
Monitoring 13Recovery ft. ft
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
79.SAND/GRAVEL PACK'(if-applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach:additionallsheets if bite ssary)
Geothermal(Heatin C oling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,gnia size,eta
�7 0 rt. 20 ft Is
4.Date Well(s)Completed: 13 2 Well ID# 20 It. L(O fL ( ROB
5a.Well Location: `1 fj ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. fL
ALA`( Aa l'Aat'A V;ems C4 (�J 9:i,� 9C 210)- ft. ft.
Physical Address,City,and Zip ft. fL
B K 21.REMARKS
County - Parcel Identification No.(PIN) AUG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Information Processing Unit
(if well field,one lat/long is sufficient) 22.Certification:
2& , 34� 60 � N --ea , 2glz � W 7113121
6.Is(are)the well(s) Permanent or 13Temporary Signature of Certified Well Conlffctor 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 MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and Nplain 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—& (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: 1190 (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: in.I/
(� ) 24b.For IniecHon Wells: In addition to sending the form to the address in 24a
6L r�/ above,also submit one copy of this form within 30 days of completion of well
(Le Well construction method:- �� /
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY /WELLS ONLY: 1636 Mail Service C enter,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: t/C�i4 24c.For Water SuoDiv&IniecHon'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: >�1 / t Amount �4� Oz 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