GW1-2021-07404_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin ® 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4518-A �' ' \y ft. �t'4 ft 8
NC Well Contractor Certification Number r9
QGQ,� 75.OUTER CASING for mutti cased;wells ORLINER rf a licable
Aqua Drill, Inc. +ar�� Q�{�o� FROM TO DIAMETER T>�cicr S MATFRML
ft. it in.
Company Name �rt+0t (�
Zc O 16.INNER CASING OR TUBING eothermal closed400
2.Well Construction Permit#: FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc) ft ft In.
3.Well Use(check well use): ft• ft in.
Water Supply Well: -17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) ft ft in.
Industrial/Commercial OReside tial Water Supply(shared)
18.GROUT
Irrl atlon ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft
Monitoring DRecovery ft. ft.
Injection Well: ft. ft
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK:if s" licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stom3water Drainage ft. ft
Experimental Technology EtSubsidence Control It. ft
Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
.Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM ft. TO DESCRIPTION color,hardness,soilfrock a in ' etc.
p. . it
4.Date Well(s)Completed: 7 /2 ► Well ID# �� ft. y'pS ft Cr fot4
Sa.Well Location: / L ft. ft
ft ft
Facility/Owner Name Facility lD#(ifapplicable) ft. ft
Physical Address,City,and Zip ft. It.
Ear s)th 21.REMARKS
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:
3 6. 1`93 YL N 80.3SA?1 W
6.Is(are)the well(s)l permanent or Temporary Signature of Certified 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 E3No 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 construct n information and explain the nature of the- copy of this record has been provided to the well owner.
repair under#2I 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: l (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2Q100� construction to the following:
10.Static water level below top of casing: J., (fL) 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: rpt^ry 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: Y 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: /'• Amount: l W� 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