GW1-2021-00295_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
l2o k 22S tt.
k. ft.
NC Well Contractor Certification Number 45.OUTER CASING for multi cased-wells OR LINER ff a licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Q ft. n ft in.
Company Name
1 '"16.INNER CASINGG
OR TUBING eothermal closed-loop)
2.Well Construction Permit#: o`l«; 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 DMunicipal/Public k. ft. in.
Geothermal(Heating/Cooling Supply) EaResidential Water Supply(single) fL ft. rn
Industrial/Commercial Residential Water Supply(shared) _18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q ft. 2•2, ft- ew s ,
Monitoring _ Recovery ft. fa
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation "19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control k. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) UnOther(explain under#21 Remarks) FROMI TO DESCRIPTION color,hardness,soillrock type,grain size,etc
D k. `1 c, ft.
4.Date Well(s)Completed: flaV 1 Well ID# ft. 7-2- fL
5a.Well Location: k. ft.
k. ft.�� ayu
Facility/Owner Name Facility ID#(if applicable) ft. It.
Physical Address,City,and Zip —� ft ft.
� /�� 21.REMARKS
Md1iL/w 1
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- too7Z N 8 0, ySS�?� W
6.Is(are)the weil(s) ermanent 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 wen: ®Yes our No with 15A NCAC 02C.0100 or ISA 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 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: 22 00 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@I00') 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 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: CO��"a V 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: 'e,�i� 1636 Mail Service Center,Raleigh,NC 27699-1636
/�
13a.Yield(gpm) / Method of test: V 0/ 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:_ Id'T� Amount: (402, 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