GW1-2021-07520_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZln 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name to ft.ft. - fL ;L
4518-A ` . f�
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR HICKNESS LINER if a licable
Aqua Drill, Inc. FROM To DIAMETER T MATERIAL
O ft. y 2 ft. in.
Company Name q
3 6 O s INNER CASING OR'TUBING eothermal dosed-loop)
2.Well Construction Permit#• W FROM To 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): fa ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
_'Agricultural OMunicipal/Public ft. M in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
-Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © 1
t. It.
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 13Groundwater Remediation
<19.SAND/GRAVEL PAGKf ita' licaBle
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test CIStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.'DRILLING LOG attach additional sheets if necessary)
Geothermal eatin Coolie Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,eoit/rock in s' etc.)
t 40 ft. fL 7ow
4.Date Well(s)Completed: Well ID# ov k. . ,5 to �lwj
5a.Well Location: ft. ft.
UVIt#440r f okw-Sri -e^rs ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ly 70 MC :KroAII& jhA4J & Or ft. ft. 5E
Physical Address,City,and Zip ft. ft. ocessing Un
AII� 2 3 21.REMARKS on
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
it. 14144 N ?4• V71 L t W
6.Is(are)the well(sermanent or Temporary Signature of Certified Well rontractor 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: 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 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 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: c SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22 1 ( ) 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@100D construction to the following:
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 Iniection Wells: In addition to sending the form to the address in 24a
Qofatfy 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 27699-1636
13a.Yield(gpm) J Method of test: pG"V 1 24c.For Water Supply&Iniection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ` Amount: Ise 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