GW1-2021-06801_Well Construction - GW1_20210809

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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 2 ft- dos ft &�G'-plt'l
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased'we Its)OR LINER a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNEss MATERIAL.
0 ft 000 It. in.
Company Name
/ !�G^ ©/I�/2�20 2 l 16:INNER CASING OR TUBING eotherinal closed-too
2.Well Construction Permit#: y"7 T b FROM To DIAMETER THICKNESS MATERL L
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. IL in.,
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. ft.
1ndustrial/commercial Residential Water Supply(shared) 18.GROUT
PIrrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well: C ft. 2 ft. ',
Monitoring Recovery ft. ft.
Te ,tlnn Well: - ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK(if,a"licsble
Aquifer Storage and Recovery 13 Salinity Barrier FROM To MATERLtL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage ft, ft.
Experimental Technology Subsidence Control fa ft.
Geothermal(Closed Loop) 13Tracer 20.DRILLING:LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) 00ther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soft/mck in size,etc
O ft. '),0
4.Date Well(s)Completed: �6 I Well ID# 77c, ft- 265 ft ( �ni Ili
5a.Well Location: ft. ft.
/VkaSon Get1Sp^ ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
nVIN
ft. rz
Physical Address,City,and Zip ft. ft.
Xat kt 21.REMARKS r; NA C��
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3 ,o .2YS I8 N $m, ygl0$ w
6.IS(are)the well(pPermanent or �Tempora Sign Certified Well Contractor Date
�� �� 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: E)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 informati 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 fo
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
i
9.Total well depth below land surface: -3 6 S (it-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �- ` (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
.Well construction method:
ram (`/ above,also submit one copy of this form within 30 days of completion of well
(L !/
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) r Method of test: VJ/�(i�C tI 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: W-H Amount: I/O Z_ completion of well construction to Ithe 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