GW1-2021-07068_Well Construction - GW1_20211129

. Print Form ;
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
k. G.S ft. c,
4518-A N 7
k. 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
". in.
Company Name
n �p '16 INNER CASING OR TUBING(geothermal
2.Well Construction Permit#: 2 ID I FROM To DIAMETER THICKNESS MATFRUL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): k. ft. in.
Water Supply Well: '17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural 13Municipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. IL
Industrial/Commercial Residential Water Supply(shared)
s'18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMO[JNT
Non-Water Supply Well: O ft. ? ft. G
Monitoring F�tRecovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediationk.
19 SAND/GRAVEL'.PACK`"if.ai livable x
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control k. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness
soiurock a raja s' etc
tI O k. [t fL �lp�i
4.Date Well(s)Completed: b y Well ID# ft- t IL
Sa.Well Location: ft. tL
f'/ P-h JV&wie, ft. ft
Facility/Owner Name I Facility ID#(ifapplicable) ft. ft.
H-wy 1 SS i M°r-ks✓d1/e�H� k.
Physical Address,City,and Zip k. M N V , 9 NZI
nn V. 2L REMARKS
I A. le.
County Parcel Identification No.(PIN) t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well
field,one WIWI;is sufficient) D 22.Certification:
35. (fag N 8 Y W �'�— � 7
6.Is(are)the well( Permanent or Temporary Signature ofCertified Well Contractor Date
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: E3Yes orbNo with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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
9.Total well depth below land surface: SOS (It.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: SO (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
9-1 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 'nor 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) 4 Method of test: b14e/hACPr' 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: ITA Amount: 1YDZ 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