GW1-2021-05916_Well Construction - GW1_20211025

��Rrrit Form.
WELL CONSTRUCTION RECORD(GW-1) For"Iriternal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
NC Well Contractor Certification Number ;,15.OiTTER.CASING'for mult&gsed wells OR LINER'(if'a Gcable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
k. G ft. in.
Company Name
16.INNER CASING OR TUB (Feather al closed-loop)
2.Well Construction Permit#: 2O 210 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft.
3.Well Use(check well use):
Water Supply Well: �17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural C)Municipal/Public k, ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) k. ft. in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. '
Monitoring Recovery ft. ft.
Injection Well:
k. ft.
Aquifer Recharge Groundwater Remediation
19.SAND7GRAVELPACK if:applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage k. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets-if necessary)
FROM TO DESCRIPTION color,hardness,wiVrock e, rain size,eta
_ Geothermal(Heatin Coolie Return) Other(explain under#21 Remarks) 0 ft• 3S ft.
16
4.Date Well(s)Completed: tO ZZ t 2(Well ID# ft. (8S ft.
Sa.Well Location:
ft. ft.
• '� ft. ft.
Facility/Owner Name V Facility ID#(if applicable) k' ft
7482 t l.. (cwf , k k. ft A It
Physical Address,,City,and Zip k• ft 1oG
'
f 7Y 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) 22.Certification:
34, 73 9 67 N 80.055 5 2., W Jam= /---- toll1-�Z(
6.Is(are)the well(s) Permanent or 13Temporary Signature of Certified Well Contractor Date
"711�" 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 ormNo 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
IQ
9.Total well depth below land surface: I V S (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q2000''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 Injection 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: Chu•V 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) 5 0 Method of test: S;G Ar 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the addiess(es) above, also submit''one copy of this form within 30 days of
13b.Disinfection type: Amount: l 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