GW1-2021-00254_Well Construction - GW1_20211213

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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 Zo ft. tt.
k. ft I
NC Well Contractor Certification Number `45.'OITfER CASING for multi cased.wells OR LINER if a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. JW ft. in.
Company Name
3�,� =16.INNER CASING OR'TUBING(geothermal closed-loop)
2.Well Construction Permit#: 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): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
:)Agricultural Agricultural 13Municipal/Public ft. ft in.
:]Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial foResidential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: tt. Z
_ Monitoring Recovery ft. ft
Injection Well:
ft
Aquifer Recharge Groundwater Remediation
39.$AND/D/GRAVEL PACK if a licable
Aquifer Storage and Recovery EISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soilfrock type rain size,etc
9 ft. C10 ft. J,
4.Date Well(s)Completed: Well EM 10 ft. ft. NG`
5a.Well Location: ft. ft
Uo hanrt- orc:Z ft. IL
Facility/Owner Name Facility ID#(if applicable) ft. ft
�^ d b.1-toye, tVZ ft. ft
Physical A:ddra,City,and Zip -- ft. ft r
4�V�L�i� 21.REMARKS '
County /Y Parcel Identification No.(PIN) 021
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if weell field,one lat/long is sufficient) 22.Certification:
llU3S q55 N go• (iY713 w i 2
6.Is(are)the well(s) Permanent or Temporary 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: EJYes orbNo with 15A NCAC 02C.0100 or RSA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction Information 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2�/ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@2000'and 2@100) construction to the following:
10.Static water level below top of casing: 7 (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
12.Well construction method V above,also submit one copy of this form within 30 days of completion of well
�O}�1r 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
(/�/'4 13a.Yield(gpm) J Method of test: V 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 0'✓� completion of well construction tol 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