GW1-2021-05572_Well Construction - GW1_20211013

V Print Form.
WELL CONSTRUCTION RECORD(GW-' }, � For Internal Use Only:
1.Well Contractor Information:
Cameron Bazing 1 1 J 14.WATER ZONES
AY-�4
Well Contractor Name FROM TO DESCRIPTION
� �CC�rc+$5��� k.
J
4518-A ��''��i O� k. ft.�rifio`r' Osd�
NC Well Contractor Certification Number 15.OUTER CASING formultl cased wells OR LINER rf.a licshle
Aqua Drill, Inc. FROM TO DIAMETER T�CtINF,SS MATERIAL
d ft. 7 ft & I in.
Company Name
(rf p O.f_�� FROM
INNER CASING OR T[JB AM(geothermal closed-loop)
2.Well Construction Permit#: `' !rw 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.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) rt ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
Iffi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. Z!� ft G 1 's
Monitoring L3Recovery k. k.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19:SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage k. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additionatsheets if necessary)
Geothermal eatin ooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,soitl o k is size,etc
ft 6S ft _,1
4.Date Well(s)Completed: "� �S Well ID# ft ?OS fL ✓1r�
5a.Well Location: k ft
✓a f rt. ft
Facility/Owner Name fiy Facility ID#(if applicable) k. ft
Jo ^ 7 rt. ft
-f� /fju,,'tt�tc ky horAG Q�
Physical Address,City,and Zip �(/���� &P4 ^/G ft ft
ya�dk/^ 2t.REMARKS.:.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) / 22.Certification: .}
3ore.2`l N gC�•f� r(26Z W
SignaCertified Well Contractor 1 Dace
6.Is(are)the well(s) Permanent or Temporary
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatio 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:
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 I 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: 70$ (ft.) 24s. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if d fferem(example-3@200'and 2 100D construction to the following:
10.Static water level below top of casing: 3 0 (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
ad Y above,also submit one copy of this form within 30 days of completion of well
f 12.Well construction method: I(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
13a.Yield(gpm) 3 q Method of test: &G`'CT- 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:4T4 Amount: 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