GW1-2021-07349_Well Construction - GW1_20210921

�b P,r:int�For:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A o ft• 20i
ft. ft. j
NC Well Contractor Certification Number " OUTER CASING for multi-casedlwells OR LINER d a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAi.
ft- I L/ It. in.
Company Name 16.INNER CASING ORTUBING eotherma lclosed-lob
2.Well Construction Permit#: q OS C! V r,/�'EL A r,/ZI FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
lGeothcrinal
ater Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.Agricultural []MunicipaUPublic ft. ft. in.Geothermal(Heating/Cooling Supply) [(Residential Water Supply(single) f ft. ioIndustrial/Commercial Residential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
on-Water Supply Well:Monitoring Recovery ft. ft.
jection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19i SAND/GRAVEL PACK'if if 'licable -Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft.Experimental Technology ®ISubsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets:if:necessa(Ileatin Coolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,wil/mck a in sirr,eta
Q O ft. S ft_
4.Date Well(s)Completed: 8 Well ID# ft. S ft.
5a.Well Location: ft. ft.
ft. tt.
V✓:nb�r' ltnvs�S���
Facility/Owner Name Facility ID#(if applicable) ft. ft.
�i 1%4 G*'bSSH/�'�- 1/Q FiW4m a.Ate ft. ft. �+
Physical Address,City,and Zip ft. ft. g�llti(�
1G+hW� CG 21 REMARKS 10 n
t ® J
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:
-3S. W/ob N 7P'• Sze v y w � �_ 1� 2G
6.Is(are)the well Permanent or Temporary Signature ofC ed 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: F3Yes 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 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: SD (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: V (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rotoril above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 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: G'`�� 24c.For Water Suvoly&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: Amount: 6a Z completion of well construction to jthe 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