GW1-2021-03924_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD(GW-1) i For Internal Use Only:
1.Well Contractor Information:
r
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A o ft• S rL 2 S GPn
ft. ft.
NC Well Contractor Certification Number '15.OUTER CASING for multitase11 wells OR LINER rf a Iicable
Aqua Drill, Inc. FROM TO DIAIIIETI THICKNESS MATFRIAt.
Q ft. y 7 ft. in.
Company Name -
L(moo2
nn(r��✓� 9v V? '16.INNER CASING OR'TUBING(geothermal closed-loop)
2.Well Construction Permit#: Iv I� 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 OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OR.sidential Water Supply(single) ft. It.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft 2 c IL G Ll(" f -t dto)
Monitoring pRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology 13 Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soivrock typa,gritins etc
0 ft. yc ft. 1�
4.Date Wells)Completed: 0/z/711 Well ID# yD h (Y S f�
5a.Well Location:
511 a�JrG ft. "
Facility/Owner Name /� Facility ID#(if applicable) ft. ft.
1"'Loovt' Ak f4l y�NG'L7o7. ft. ft. rsi', �j1S1t
Physical Address,City,and Zip fL ft
3; O
21.REMARKS; t""' :;�S:•"_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
Y o(8 6,,.,�` N c, 232 5 W �' 2 2
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contractor Date
j- 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: ®Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill old known well constriction informatio and explain the nature of the copy ofthis 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: 1 /S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdigerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: o A (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
{� l/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 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
y
13a.Yield(gpm) 2 5 Method of test: 61AG kCT 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: ffTk Amount: WZ_ 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