GW1-2021-04138_Well Construction - GW1_20210823

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well COntI8C10L Name FROpM TO DESCRIPTION
/
4518-A
1)ft. b s f�
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER rf a livable
Aqua Drill, Inc. FROM TO DIAMETER TLItCIINESS MATERIAL
8 5
ft. ft.
Company Name
jr
16.INNER CASING OR TUBING eothermal closed-loo
� /�
2.Well Construction Permit#: M 1 1 �2( 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 SITS TIDCKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) prResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: to ft. �j ft. t
Monitoring Recovery ft. ft.
Injection Well:
It. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control It. M
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
q����( Q ft. ft. N
4.Date Well(s)Completed:-�� Well ID# ft. y ft `r!iwa/
5a.Well Location: ft. ft.
Tawb I{eon Q,
ft. ft. �R
Facility/Owner Name Facility ID#(if applicable) ft, ft.
28 y/ y��r srd�a,/IrG 27v/4 L ft.
Physical Address,City,and Zip ft' fL �r t,rvSl" r
Z/Ad k/1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
3 6. 29 7-3 3 N vim • 57 W
6.Is(are)the well(slit'lOPermanent 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: [3Yes or ONo with 15A NCAC 02C.0100 or]5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and 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:
S.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 neede(L 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: 3 Y (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 2@100) construction to the following:
10.Static water level below top of casing: Ar 90 (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
�1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: dec t°�• Y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L Method of test: 13 4 r,tGr 24c.For Water Supply&Infection 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: �Ca L completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016