GW1-2021-07377_Well Construction - GW1_20210921

' ,.r..in .Form .
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: i
1.Well Contractor Information: 7
t
Cameron Bazin 14.WATER ZONES
FROM TO DESCRIPTION '
Well Contractor Name r
00 k' *7e ft.
4518-A k. ft. !
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERW
ft. O ft. in.
Company Name
`16INNER CASING OR TUBING eothermallcitised-loo'-
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,variance,etc.) k, ft In.
3.Well Use(check well use): k. ft. in.
Water Supply Well: 17 SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agriculttual [)Municipal/Public k. ft. in.'
Geothermal(Heating/Cooling Supply) residential Water SuppJm
fL ft. in,
Industrial/Commercial Residential Water Supp18.;GROUT
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring Recovery k. ft
Injection Well: k th
Aquifer Recharge Groundwater Remediat
19 SAND/GRAVEL PACK if a livable
Aquifer Storage and Recovery Salinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®IStormwater Drainageft. k.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING.LOG attach additional.sheets if necessary)
FROM TO DESCRIPTION color,hardness,willrock rain size,etc.
Geothermal(Heating/CoolingReturn) Other(explain under#2
4.Date Well(s)Completed:T I Well ID# Z,
ft' .� ft r«wrf•�
ft. ft.
5a.Well Location:
ft. ft
itak,e
Facility/Owner Name —r Facility lD#(if applicable) k• ft
YCI 772 H'`"r F *L k. ft. SEP
Physical Address,City,and Zip ft ft
S { O(��i S 2L REMARKS ili k
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat(long is sufficient) p 22.Certification:
�G j9'307 N &p . 095�� W
6.Is(are)the well(sPermanent or [ITemporary Signature ofCertified Well Contractor Da-
By 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 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 informatiog6nd 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-I 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: 62 + (ft-) 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: S (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
/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: �b�a` V 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) ��2 Method of test: 6W k.,/ 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: T�' Amount: (66'7_ 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