GW1-2022-06059_Well Construction - GW1_20220629

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Print Form
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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
FROM TO DESCRD:TION
Well ContractorName J q S fL n
4518-A f ft.
NC Well Conhactor CertificationNumber 15.OUTER CASING for ma d-cased wells OR LINER if a Hcable
Aqua Drill,Inc. IROM TO DIAMETERI THICKNESS MATERIAL
® ft D
Company Name 16.INNER CASING OR TUB G(eothermd closed-loo
2.Well Construction Permit#: FRo61 To DtAnIETEtt THICKNESS MATERIAL
List all applicable well corsirnction permits(I.e.121C,Count};State,Variance,etc) ft• ft.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DTAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural M it cipallPublic ft ft in.
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) ft ft, in.
,.lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
t—itHeation FROM I TO MATERIAL EMPLACEMENT It'IETHOD&AMOUNT
Nola-Water Supply well: @ ft 2S ft
Monitoring 011ecovery R ft.
Injection Well: ft, ft
12Aquifer Recharge DGroundwaterRemediation
19.SAND/GRAVEL PACK of a Iirable
_.Aquifer Storage and Recovery Salinity Ban]er FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft ft
NExperimental Technology 1oSubsidence Control ft. ft
Geothermal(Closed Loop) [3Tracer 20.DRII LING LOG attach additional sheets if necessary)
Geothermal(Heatmg(Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,bardum.solUrock tytm Praia size,eta
4.Date Well(s)Completed: !� Well ID# Q It �Q
ft. reA
ft. ft.
5a.Well Location:
Facilt��ame Facility ID#(if applicable) ft ft
ficylt'lQn OoIAl— G^gaQ-A:, fL ft
Physical Address.City,and Zip ft. ft
21.REMAIIICS
County ParcelIdeutification No.(PIN) 71
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(ifweil field,one Mongis sufficient) 22-Certification:
-35-211 2— 1v & �;7o$j W
6.Is(are)the well(s)oPermanent or OTemporary SignatareofCertifiedWellContractor DEC '
By signing this form I hereby certi&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: IDYes or Y-JNo with 15ANCAC 62C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill and brown well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under#21 remark section or on the backof Uusform. 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: 7�/ (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2Q100) construction to the following.
10.Static water level below top of casing: So (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing use"+- 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (i •) 24b.For Infection 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: construction to the following:
(Le.auger,rotary,cable,duectpus%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) *3 Method of test 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: Amount: f,C297 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