GW1-2021-05547_Well Construction - GW1_20211013

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION�„s \\
4518-A 2 2&� 9LS 20 rn
iL
NC Well Contractor Certification Number ��\11�
,y\pGL" 15.OUTER CASING for multi cased wells OR LINER da 1[cable
Aqua Drill, Inc. t�3���i �Q6"OCt FROM TO DIAMETER TIOCKNESS MATERIAL
ft. ss ft. in.
Company Name
3 2 O 9'( 16.INNER CASING OR TUBING eothermal closed-loon)
2.Well Construction Permit#: / FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL.
Agricultural [3Municipal/Public ft, ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) h. ft. in.
Industrial/Commercial 1-0 Residential Water Supply(shared) .18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 II A( fL
3 Monitoring Recovery
Injection Well:
ft.Aquifer Recharge [3Groundwater Remediation ft.
19.SAND/GRAVEL PACK if applicable)
'Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL&ftEMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. it.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
NGeothermal eatin COohn Return) Mother(explain under#21 Remarks) FROM
TO DESCRIPTION color,hardness,wiltrock a rain sk etc.)
A9 ft. q S iL
4.Date Well(s)Completed: / Well ID# y s ft. 32>~ fL /
5a.Well Location: ft. ft.
f0►A1C01 �,1reo�oL ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. FL
S 90 AMAY-A IZA ft. ft.
Physical Address,City,and Zip ft. fL
2o,;.,"Qn 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9 1 22.Certification:
3S .S72es N 80. 71 C 7 6Q 7 W
6.Is(are)the well(s) permanent or Temporary Signa ofCerti�l Contractor Z
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 1 SA NCAC 01C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction inforr io d 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 ofthis 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: 3 2 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 1Qa 100D construction to the following:
10.Static water level below top of casing: SG (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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rota w 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) 20 Method of test: 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: �oZ completion of well construction to the county health department of the county
where constructed.
Yom OW-1 Notth Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016