GW1-2021-07633_Well Construction - GW1_20210903

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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 DESCRIPTTON
4518-A ydo ft. �oo it. ( _
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING formulti cased wells`OR LIlHER'tf a licabte
Aqua Drill, Inc. FROM TO DlAIviETER THICKNESS MATERIAL
Q ft. /�0 ft. in. i 7
Company Name v
Zy Z p 16.INNER CASING OR TUBING' 'othermal ctosed400
2.Well Construction Perm O it#: —20 Z,I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It, in.
3.Well Use(check well use): & ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooting Supply) Residential Water Supply(single) ft. ft. is
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. 2, ft. G11. :S /-mti(Ga T
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK if.a licahle
'Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �I Stormwater Drainage ft. ft.
Experimental Technology ®I Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer 20.DRILLING LOG attach additional sheets if neeessa
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIP'fION color,hardness,soiumck type,grain size,etc.
O ft. S a & Sup
4.Date Well(s)Completed: yIZ( Well ID# 0 ft. 6®s IL t ,
5a.Well Location: ft' ft.
ft. ft.
4G/5 011
Facility/Owner Name Facility ID#(if applicable) ft' it.
R Y&4Ic h✓,'l/c, /YC ft. rt 1
Physical Address,City,and Zip ft. ft.
Yak 21.REMARKS
County Parcel Identification No.(PIN) .'rJt10V\ 2C�i0
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(i£well field,one lat/long is sufficient) 22.Certification:
3(" .F y lYG N o0 767yS w •5/ z
6.Is(are)the well(s) Permanent or Temporary Si�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: ®Yes or
with ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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 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: (00 S 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3Qa 200'and 1@100D construction to the following:
10.Static water level below top of casing: y�o (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: lC/ (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: Po+u C construction to the following:
(Le.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: htiG Lr r 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: I�0 Z 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