GW1-2022-01903_Well Construction - GW1_20220210

EA,t s`Prm��Form�-�,r'
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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 1at.wATERZONES
FROM TO DESCRIPTION
Well Contractor Name ft. '?05 fL iJ
4518-A ft. ft. 7
NC Well Contractor Certification Number 15:`:OUTER CASING.for multi-cased;whlls OR INNER'. a"ltcable
Aqua Drill, Inc. FROM To DIAMETER THIC[INESS MATERIAL
ft. L�O ft.
Company Name 013
( S� ` &INNER CASING OR TUBING"cothermal closed-too
2.Well Construction Permit#: IL//1 ✓ FROM TO DIAMETER TI�CKNESS MATERIAL
List all applicable well construction permits(i.e.WC,County,State,Variance etc.) ft• ft In.
3.Well Use(check well use): ft. ft. in
17;SCREEN
Water Supply Well: FROM I TO I DIAMETER rI SLOT SIZE I THICKNESS I MATERIAL
Agricultural IOMunicipaUPublic ft. % in.
Geothermal(Heating/Cooling Supply) Rkesidential Water Supply(single) fL ft
Industrial/Commercial DResidential Water Supply(shared) 18':GROUT
Irrigation FROM TOMATERIAL EMPLACEMENT METHOD&AMOUNT
[Aquifer
ater Supply Well: ft• q ft
itoring �Recovery ft. ft
ion Well:'- ft fL
ifer Recharge Groundwater Remediation
:A%SAND/GRAVEL PACK-if:a.licable
fer Storage and Recovery OSalinity Barrier FROM To MATERIAL EMPI ACEMENT METHOD
Test IO_.Stormwater Drainageft• it.rimentalTechnology ISubsidenceControl fL ft•
Geothermal
ed Loop) OTracer 20.
hermal(Heating/Cooling Return) Other lain under#21 Remarks FROM DRILLING
To O f DESCRIPTION(co or,t .
ION rnlor,hardness,soiUrock e, is eta
4.Date Well(s)Completed: lilt ZZ Well ID# Lha ft. S ft-
ft
5a.Well Location: ft.
Facility/Owner Name —� /�' Facility/ID#(if applicable) ft. ft
/I 6e— SAc� ( � 4 ��✓/�/G ft. ft
,�J,_,�
Physical Address,City,and Zip ft ft e�
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 ffi sucieat) 22.Certification:
5�- 10735 N 9o.! '3S 82- w "4 y
6.Is(are)the well(s)
-ermanent or OTemporary Signat&of Certified etl Contractor Date
�,f By signing this form,I hereby certify that the ivell(s)was(wise)constructed in accordance
7.Is this a repair to an existing well: ]Yes or No with 1 SA NCAC 02C.0100 or 1 SA 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 wider#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: o (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(a)200'and 2@100) construction to the following:
10.Static water level below top of casing: S6 (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: Y
/O,r above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct pushy etc.)
Division of Water Resources,'Undergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13s.Yield(gpm) 3 method of test: 1Z1A C� e 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: / Amount O 7 completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016