GW1-2022-05955_Well Construction - GW1_20220615

Print Form __
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
L Well Contractor Information:
Cameron Bazin 14.WATERZONES
FROM TO DESCRIFriON
Well ContractorName s' iti
4518-A ft
ft. ft.
NCWellContractorCertifirationNumber 15.011TERCASING for1!2L_asedlve% ORLINSR d`a licable
Aqua Drill, Inc. FROM TO DIAMETER TDICKNFSS MATERIAL
e. s0 in
CompanyName /
16.lNNER CASING ORT[1BING eotherinal closed-moo
2.Well Construction Permit#: FROM I TO DIAMETER I TMCKNESS MATERIAL
List all applicable well construction permits(4 e.UIC,Como,.Stale,Variance,eta) a. ft. in.
3.Well Use(checkwell use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TIHCKNESS MATERIAL
Agricultural DMunicipal/Public fL ft. in.
Geothermal(Reating/Cooling Supply) E3kesidential Water Supply(single)
tt ft in.
IndustdaVCommeroial ebRcsidential Water Supply(shared) 18.GROUT
=JIrrigation FROM TO MATERIAL EMPLACEMENT hIETHOD&AMOUN T
2I ft:
Non Water Supply Well: 0 tt `� {�
Munitoring DRecovery ft. %
Injection Well:
ft. ft.
AquiferRecharge []GroundwaterRemediation 19.SANDiGRAVELPACK ifa ticable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 'DStormwater Drainage ft. ft.
Experimental Technology IOSubsidence Control fr. IL
Geothermal(Closed Loop) [3Trdccr 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) MOther(explain under#21 Remarks) FROM TO DISCRIC[ION color,hardness,soilfrock type,grain size,ere.)
i
Q tt. YD ft
4.Date Well(s)Completed: ZZ Well ID# s/D
5a.Well Location: R' H:
fc ft
Facility/Owner Name FscRity 1D#(ifapplicable) R- ft.
WA " ! ft. ft.
Physical Address,City,and Zip % ft. v r. I V U
�rr�1 21.REMARKS
County 4F Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22_Certification: J •cw r �f
. tification: {�*(�.,�rrg} �n �,t��e� G UNIT� 2or,(�i
6.Is(are)the well(s)il/><Permanent or E3Temporary Sigoatme o rtified Well Contractor Date('
11`' By signing this form,I hereby cer46,that the we11(s)mos(were)constructed in accordance
7.Is tbis a repair to an existing well: I�Yes o NO 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 constructea+fnfarmatt and explain fire nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
8.For GeoprobeiDPT 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
/4['
9.Total well depth below land surface: ( 2 7 (ft•) 24a.For All Wells: Submit this fort within 30 days of completion of well
For multiple wells list all depths if&r;ferent(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: �0 (ft-) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Cm•) 24b.For Infection Wells: In addition to sending the form to the address in 24a
/�,, /S above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 7 Oar 1/
(i.e.auge,rotary,cable,direct push.eta) construction to the following.
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
n
13a.Yield(gpm) 20 Method of test: �I 4G'i D` 24c.For Water Supply&Iniection Wells: In addition to sending the form to
r�L�L the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: !LY Amount �� 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 2r22 2016