GW1-2021-06802_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 ft. t o ft. 2 G P01
ft. ft
NC Well Contractor Certification Number 15.'OUTER CASING for multi cased wells)AR'LINER rf:i livable
Aqua Drill, Inc. FROM TO DIAMETER Tin MATERIAL
MATERIAL
Company Name
� 1 f D rt in.
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: e,/5/4 O(22,yo—22o21 FROM TO DIAMETER THCKNESS 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. i❑.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) MRcsidential Water Supply(single) ft. fL
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. rL V/ ft. L�r S e O et I o C-_' &dlCtr�A_
Monitoring DRecovery 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 [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E2Tracer 20.DRILLING.LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
D ft. 9 a ft. (ZA 0111X
4.Date Well(s)Completed: 7 Z( Well ID# g p ft. ((zv ft. pa
5a.Well Location: Sao ft' Y 0S it- 6,rA-14'
Facility/Owner Name Facility ID#(if applicable) ft. fL
y,�z c, /-zJ F s`� ,uG ft. ft.
Physical Address,City,and Zip 2 7-If
21.REMARKS j. ., i�Q•+4 aG� 1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iffwell field,one lat/long is sufficient) 22.Certification: zl
6.Is(are)the well(s) Permanent or 13Temporary Signature ooTCertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
r No with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: �Y¢s O
Ifthis is a repair,fill out known well construction informatidnn and explain the nature of the copy ojthis 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: ��S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@2000�''and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
y�o+/1 r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / Y 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) Method of test: tnt:��� 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: 14TN' Amount: 1V//O Z 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