GW1-2022-08490_Well Construction - GW1_20220510

rFrint,Form a
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRU'TION
4518-A
300 ft. ft. '
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING.for mul6,cased:wells OR LINER if a liable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. 2 ft. in.
Company Name ��� SSo 16.INNER CASING ORTUBING(geothermal closed-loop)-
2.Well Construction Permit#: 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.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in,
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METFIOD&AMOUNT
Non-Water Supply Well: ft. 2z ft.
Monitoring _ Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
.]9.SAND/GRAVEL PACK'if.a liable
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20 DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) r30ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/mck type,grain size,etc
p ft. 0 ft
4.Date Well(s)Completed: . 1 Well ID# 7 y ft TO it- kmkz
5a.Well Location: ft. ft.
1' lui a m C X f-ri nNcl' ft. ft.
Facility/Owner Na a/e v Facility ID#(if applicable) ft. IL
''I� �w�/ �i✓O�y ^�e�VAALft/J�i ft. fL • C
Physical Address,City,and Zip ft. ft. MAY I
DAV�L.. 21.REMARKS
t'rr�c
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweldfield,one latliong is sufficient) n Oy 22.Certification'3S I 9Z V2� X N r 1Z.449 W — 1 �p
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
f� 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: ® 1/'Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information j6d explain 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: 707 (It.) 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@100� construction to the following:
10.Static water level below top of casing: So (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.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
u�y 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: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '/4 Method of test: "eKC 24c.For Water Supply&Infection Wells: In addition to sending the form to
I //-- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: �(0p2 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