GW1--03134_Well Construction - GW1_20230505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A ' r✓6S ft. ft. i 5) 6 .'11
iL ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased welts)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO I DIAMETER THICKNESS MATERIAL
-
0 Company Name ft
in_ /�
/ r" C.,
"� 7J� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: C� / FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(11C Coun(y.State.Variance,etc) ft. R in.
3.Well Use(check well use): it, ft in.
i Water Supply Well: 17.SCREEN
A cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ftt Municipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation
FROM MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: L� ft ; 7 it
Li
Monitoring Recovery ft I ft
ft. G t"
Injection Weil:
ft.0- Aquifer RechargeEi
GroundwaterRemediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL r11iFLACEh1EtrT M THOD
Aquifer Test 0Stormwater Drainage ft ft
Experimental Technology QSubsidence Control ft ft.Geothermal(Closed Loop) Tracer 2D.DRILLING LOG(attach additionalsheets If necessary)
DGeothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock hpe grain:tom erel
C--) ft.
7 J ft 4. AG/ _
4.Date Well(s)Completed: (VZ-(f 2-'2 Well ID# 6 it 2?-5 ft. gO1 G7
5a.Well Location: tr. ft
re, f y4= 'L'i. 4 id
Facility/Owner Name Facility Mg(if applicable) ft. ft'
^^ 1}r id Ar,�,- ft. MAY J . 20/3
Physical Address,City,and Zip ft
21,RE1IAILKS ',Y(?C' '-'1 rrr-C 5.-,4 9 Ur i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lot/long is sufficient) 22.Certification:
, ; 371 ciS1 a `y,S(r' 5 w tY�</'
/ ,
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby cer0'that the well(s)mar(were)constructed in accordance
7.Is this a repair to an existing well: QYes or, withNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constnrclion Standards and that a
If this is a repair,fill out Imam well construction informal'of and explain the nature oldie copy of this record has been provided to the well owner.
repair under#21 remarks section or an the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessa y.
drilled:
SUBMITTAL INSTRUCTIONS
ai
9.Total well depth below land surface: 2- ft
( ) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ijdifferent(example-3Ga 200'and 2@100') construction to the following:
10.Static water level below top of casing: %0 (ft.) Division of Water Resources,Information Processing Unit,
Ijwales-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
12.Well construction method:
,�G1 t,-, YI.; above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(Le.auger,rosary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEJJ.S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l Method of test: ?V 24c.For Water Supply&Injection 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: HT,- Amount: C 7,-*" 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