GW1-2021-06191_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZln 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
VS k. ft. Q_
2&5f7'1
k. fG
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a' livable
Aqua Drill, Inc. FROM To DIAMETER TIIICIINESS MATERIAL
ft. toit in.
Company Name
O1 Zo°(o "�2i1 "1 .INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: , FROM To DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. It in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public k. ft. in.
Geothermal(Heating/cooling Supply) Residential Water Supply(single) ft. ft
Industrial/Commercial Residential Water Supply(shared) ,18.GROUT
bri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 k- 22. ft
Monitoring Recovery k. ft
Injection Well:
ft ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
'
Aquifer Storage and Recovery 1ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology 13 Subsidence Control ft. ft
Geothermal(Closed Loop) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM ft ft TO DESCRIPTION(color,hardness,soiUrack rain six etc.
to
4.Date Well(s)Completed: Well ID# too ft. 1126
ft
5a.Well Location: ft ft
Mb,.k Si Sk ft ft
Facility/Owner Name Facility ID#(if applicable) k. ft 2�
q6,2-1 k. ft nit
Physical Address,City,and Zip ft ft torrn3Cloll
t n
Y� 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:
16, I7,27S N �. �°�8 01 W
6.Is(are)the well(s) Permanent or Temporary Signature of C fled Well Contractor Date
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 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 thus 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: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiiffmnt(example-3(200'and 2Q100) construction to the following:
10.Static water level below top of casing: 56 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 0 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: m.l�
(� ) 24b.For Infection Wells: In addition to sending the form to the address in 24a
,r,/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method, ���L'' V construction to the following:
(i.e.auger,rotary,cable,direct pasty 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) 2,J Method of test: 24c.For Water Suably&Infection 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: U21k Amount:_ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016