GW1-2021-00255_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZlfl 44.WATER ZONES'
Well Contractor Name FROM TO DESCRIPTION
4518-A ! 7
ft' / ft. 2'
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING for muldtased wells OR LINER a livable
Aqua Drill, Inc. FROM TO DIAMETER TTIICKrrESS MATERIAL
ft. S 0 f4 in.
Company Name
2116.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: Ups FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft.ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft. in.
IndustriaUCommercial 13Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. So ft-
1
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(it-applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) 00ther(explain under#21 Remarks) I FROM TO DESCRIPTION color,hardness,soillrock type irain size,etc.)
O ff. Yo it.
4.Date Well(s)Completed: Well ID# fic ft. is ft.
5a.Well Location: ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
Physical A dress,City,Ld Zip ft. ft
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:
34.4 l 54.7 N a0.Sri W
6.Is(are)the well(s)Opermanent or Temporary Signs re of Certified Well Contractor Date
7T 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: 13Yes or RINo 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 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 2 L C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7 v 7 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 (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 Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
above,also submit one copy of this form within 30 days of completion of well
�d / construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: is
5 tLA-T 24c.For Water Supply&Infection 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�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