GW1-2021-07434_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.
Well Contractor Name FROM TO DESCRIPTION
4518-A goo ft. Y to ft So
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for T!Lftl cased!we[Is"OR LINER :a licable
Aqua Drill, Inc. FROM TO DIAMETER TIICKNESS MATERIAL
ft. G ft. 6 in.
Company Name
3 S 2 ( 16.INNER CASING OR TUBING eothermal elosedauo"
2.Well Construction Permit#: G ! FROM To DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits fl.e.UIC,County State,Variance,etc.) ft. ft. In
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I7.SCREEN1.
_ Agricultural �Municipal/Public ft. ft. in.
m FROM TO DIAMETER ! SLOT SIZE THICKNESS MATERIAL
:
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft, ft, in.
lndustrial/Comercial Residential Water Supply(shared) 1&GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ® ft. �3 ft.
Monitoring . Recovery ft. ft. —
Injection Well:
ft. ft.
+Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL, EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal ocatinglCooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION color;hardness,soilfrock type,grain size,etc
0 ft. y6 fL S
4.Date Well(s)Completed: MAP Well ID# 'Yo ft. I y%, ft
5a.Well Location: ft. ft
0-A1 t.OGa- hoNyo's ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
l S T J/ Wim,10 Al 62416k gg kZ 27046 ft ft. 1 Z
Physical Address,
Address,City,and Zip ft ft u01i
7kG� 21.REMARKS Ip11
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:
Y 7 1 Y$ N $v.oSSdir
W
6.Is(are)the wells)! Permanent or OTemporary Signature of Certified 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: OYes or ONo 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 information and explain the native of the cop),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-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: 4 YO (fk) 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 2@1001 construction to the following:
10.Static water level below top of casing: 70 (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: *4� (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: ro*riLlr 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
139.Yield(gpm) 5O Method of test: �f�'kG� 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: �bZ^ 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