GW1-2021-03925_Well Construction - GW1_20210823

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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 00 rt• Mo rc o
ft. ft.
NC Well Contractor Certification Number
5.OUTER CASING for multi cased wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. d ft in.
Company Name
pR WL e'f f^�_Z, D�� y 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM To DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): fit. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared)
d8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. so ft• G O
JI
Monitoring Recovery ft. fa
Injection Well:
ft. ft.Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
1. Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. IL
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardy soiVrock type,grain size,etc
k. ft. 5.�
4.Date Well(s)Completed:T� Well ID# h fL ''
5a.Well Location: ft. ft.
LOJ•11G ft. ft.
� Jlb� S
Facility/Owne Name Facility ID#(if applicable)
ft. ft. °
-b Y Of DIYaV� ko+�.... Tr' ,MD' ire- rt. ft.
Physical Address,City,and Zip 70'� ft. ft.
S {V 21.REMARKS I M,Ol t
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) A pp 22.Certification:
3h a S 2507 N L'O_ S SO?Z W
6.Is(are)the well(s)�Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®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 informationj4nd 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 welljdetails:
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: O (fit•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@ 00'and 2@100) construction to the following:
10.Static water level below top of casing: O© (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 Iniection 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:
(i.e.auger,rotary,cable,direct push,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) No Method of test: 604*01- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
�.y the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: ' ` /Amount: ( 4 Zi 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