GW1-2021-06192_Well Construction - GW1_20211025

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: orm ,;,.;
1.Well Contractor Information:
Cameron BaZln 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A S ft- s
ft. ft.
NC Well Contractor Certification Number ".15.OUTER CASING for multi-cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. 0 fL in.
Company Name
+ 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: tN 13 0 [JP ZI FROM To DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. fL In.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []MunicipaL/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft, fL in.
Industrial/Commercial UResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 2 ft. h �
Monitoring E3Recovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL:PACK if applicable)
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. fL
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) ®ITracer 20.DRILLING.LOG'attach additional sheets if necessary)
FROM ;TO DESCRIPTION color,hardness,willrock rain size,etc.
Geothermal(Heatin Coolin Return Other(explain under#21 Remarks)
ID fL Za fL
4.Date Well(s)Completed: b S Z Well ED# Zy
ft. G fL Ir
Sa.Well Location: ft. fL
ky� (,✓rnl/40Gk fL fL
Facility/Owner Nanfe Facility ID#(if applicable) it• fL
I(mac LGAar 6(rS 1 Gl- CAJT Off&6- ft. ft. 21
Physical Address,City,and Zip fL IL
I111
21.REMARKS
County Parcel Identification No.(PIN) �n '\NP g$GtlO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Q ` 22.Certification:
3`f � 17A a N of W
6.Is(are)the weil(s) Permanent or Temporary SignaV ofCertified Well Contractor Date
r 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: ®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 information 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:
S.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 ifdifferent(example-3@2000'and 2@I00) construction to the following:
10.Static water level below top of casing: JO (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
�Q��11 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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: N 24c.For Water Supply&Injection Wells: In addition to sending the form to
L_ the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amount: (,DyZ- completion of well construction to ae 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