GW1-2021-00294_Well Construction - GW1_20211213

�.'��Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: V V
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRFPTION
4518-A ft. To S fL 3
k. ft.
NC Well Contractor Certification Number '15r OUTER CASING for multi cased wells OR LINER tfa 6cable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
O ft. 0 ft.
A ' �O 26�f "'46.INNER CASING OR TUBING eothermal dosed-loop)
2.Well Construction Permit#: G FROM I To I DIAMETER I 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 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: k. 20 IL t s NrQa�
Monitoring Recovery ft, ft.
Injection Well:
k. ft
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK ifapplicable)
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) 13Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) Mother(explain under 421 Remarks) FROM k. To ft. DESCRIPTION color,hardness,soillroek rain s' etc
4.Date Well(s)Completed: ZI Well ID# 470ft. 24 S ft.
Sa.Well Location: ft. ft.
P.o s;+i yo Aft (4'
Facility/Owner Name Facility ID#(if applicable) ft. ft.
r
�y7 �lod"►�I'owtn � Eo+S�l�e►,d,� ft. ft
f
Physical Address,City,and Zip
ft. ft.
REMARKS 2071
F^
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:
3 k tic 6If N 10.s0o34 W
6.Is(are)the well(s MPermanent or E)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: Yes or �No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a!!!!n"`"'"d""""'"'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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3o S (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: (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 lnjection 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: kU 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 27699-1¢36
13s.Yield(gpm) Method of test: tA0 C 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: 17, 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