GW1-2021-00297_Well Construction - GW1_20211213

�,�PrinNorm �
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
g• 5 ft
4518-A 7
ft. ft
NC Well Contractor Certification Number A5.OUTER CASING for multi-cased wells OR LINER if a licable
Aqua Drill, Inc. FROM To DIAMETFR THICKNESS MATERIAL
ft. ft 6 in.
Company Name �j "16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit#: 013 2-6/`�/ - FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft, ft 1°'
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural [2Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) fL ft in.
Industrial/Commercial residential Water Supply(shared) 18.GROUT
Irrl ation T FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. � ft
Monitoring Recovery ft. ft
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a livable
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) ®ITracer 20.DRILLING LOG'(attach additional sheets if necessary)
Geothermal eatin Coohn Return Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,will o k type,gmin s' etc.
a ft 3o & SAni
4.Date Well(s)Completed: Ti Z Well ID# ft' Sos ft 6(p„
5a.Well Location: fL ft
Owe y rV�l� ft ft
FacilityFacili y/�e Facility ID#(if applicable) ft. ft i
S llo Qnkew (A has,�A, ft. ft
Physical Address,City,and Zip 7 ft ft Z021
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:
3 6. 2 i log N 30. W k'� 2241
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor Date
OR By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E3Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff this is a repair,fill out known well construction information Sonderplain 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: So (ft.) 24s. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: f 0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use'•+j 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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: GQ1_6A c y 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
13s.Yield(gpm) Method of test: 0WA-'� 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: wit Amount: U ze completion of well construction to;the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016