GW1-2022-03097_Well Construction - GW1_20220307

ALL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin
'.14:WATERZONES'.. . ... .,. . . ,.:<..
FROM TO DESCRIPTION
Well Contractor Name ft. �s+ & '7
4518-A L` ft IL J
i
NC Well Contractor Certification Number 15.:OUTER CASING'foi muhi-case8 wets OR'I:IlYER a' l bj1
Aqua Drill, Inc. FROM To D R THiQQVESs MATERW.
/1 fL t0 %
Company Name
rf N J/�f'� � .16.INNER CASING ORTUBING `"ermatclosed=trio
` :
2.Well Construction Permit#: 1 iD 7_WI �" 06i VV/[� ROM TO DLM%MnMR THICKNIZ5 MATERIAL'
List all applicable well constntctian permits p.e.UIC County,State-Variance,eta.) a fL In.
3.Well Use(check well use): ft. ft. In.
SCREEW
Water Supply Well: FROM TO DIAMETER SLOTSIZ6 THICKNESS MATERIAL !
Agricultural OMunicipal/Public & ft In.
Geothermal(Heating(Cooling Supply) esidential Water Supply(single) lo.
Industrial/CommeroialE Residential Water Supply(shared) 1&GROUT od
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft- -ft 42nertfL
Monitoring ORecovery fL ft.
Injection Well: fL ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK fif.armlicable :
Aquifer Storage and Recovery OSalinityBarier FROM I TO MATERIAL EMPLACEMENTMEMOD
Aquifer Test OStoanwater Drainage ft. fL
Experimental Technology EpSubsidence Control % ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LUG attach additional sheets if n
Geothermal(Heating/Coo' Retum) Other(e lain under#21 Remarks) FROM fL To DESCR1MON eotor hardna%milfrock a io ' eta
O 120 fL AMA
1
4.Date'Well(s)Completed: 2 Well IDfr f` n
ft. ft.
5a.Well Location:
I, o� I ft ft
Facility/(OwnertNamee/�qr•t� Facility ID#(ifapplicable) ft. ft. I
SseO cu'("."tor( �'��/��G�tY GA NG ft. ft: 7
Physical Address,City,and Zip
fL ft.
21.REMARKS. f
1
.mod
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwell field,one latnongis sufficient) 22.Certification:
3 G. rs8 Z N ?9. 9'So yi W2(1 2
6.Is(are)the well(s)�Permanent or Temporary sign ro ofCettiS ell Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
1.Is this a repair to an existing well: DYes or OnNo with ISA NCAC 01C.0100 or ISA NCAC 02C_0200 f7ell Construction Standards and that a
If this is a repair,fill out known well cmtstntetion information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 trmarks section or on the back ofthisform. 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 w r��tell depth below land surface: J y S (ft-) 24a.For All Wells: Submit this fora within 30 days of completion of well
For multiple wells list all depths ifdifferew(example-3QQ 200'and 2@100) construction to the following:
10.Static water level below top of casing: 49 01L) Division of Water Resources,Information Processing Unit,
If uwatei level is above casing,use^+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. fin.) 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
12.Well construction method: / fioKV construction to the following
(Le.auger,rotary,able,direct push,cta)
DlVlslen of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
13%.Yield(gpm) ✓ Method of test" G ke- 24c.For Water Suonly.&Infection Wells: In addition to sending the form to
/j the address(es) above, also submit one copy of this form within 30 days of
I3b.Disinfection type: �ti► Amount: O completion of well construction Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016