GW1-2021-07347_Well Construction - GW1_20210921

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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 o o
NC Well Contractor Certification Number 15.OUTER:CASING for multitased� lls OR LINER if.a feeble
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. 60 ft. in.
Company Name �
y o S d wE f liz( 76.INNER CASING OR TUBING eothermal'closed-loo
2.Well Construction Permit#: 1� 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): ff It. In.
97.SCREEN
Water Supply Well:
FROM TO DIAMETER- SLOT SITE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 20 ft G(s� 1s rd
Monitoring 13Recovery ft. ft.
Injection Well: ft ft
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK-'if;a"livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING:LOG attach additional sheets ifinecesrssa
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiVroek a rain s' etc
Q c. 0 ft S'S ft
Z7 ['
4.Date Well(s)Completed: V ll Well ID# 4S ft. �S ft 7 ,�
5a.Well Location: ft. ft
WL^Os.O t• t 1V��r,.�sM.f'S k. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
7 122, cfdsst,���a. fJ(t C=val.�sc:�ib,Nc. ft. ft 02
Physical Address,City,and Zip ft ft 00t
A 21.xEMARKs. C
cmull
County Parcel Identification No.(PIN) �Pt�0Il3 R 5e
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one hat/long is sufficient) 4 22.Certification:3S. 17104 N W
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
011f`` 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: [3Yes or with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
_ If this is a repair,fill out Imown well construction informatio and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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: SUBMPITAL INSTRUCTIONS
9.Total well depth below land surface: 00 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: I
I
10.Static water level below top of casing: 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 Infection Wells: In addition to sending the form to the address in 24a
(b`{-a f V 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 276994636
13a.Yield(gpm) 10 Method of test: i6 eke T- 24c.For Water Supply&Infection Wells: In addition to sending the form to
r �7— the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: ✓ 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