GW1-2022-03096_Well Construction - GW1_20220307

�• ': .Pr•nt:�Form:::: �.:.
WELL CONSTRUCTION RECORD(GW-I) For Intemal Use Only:
I.Well Contractor Information:
Cameron Bazin 14:.WAT&RZONES'. r:_::. ...
FROM TO DESCRIPTION
Well Contractor Name R' YS ft.
4518-A R, fL
NC Well Contractor Certification Number 15:OUTER'CASING' orma1d-c W.1,welis ORLWM da linable
Aqua Dt111, Inc. FROM TO DIAMETER . T>Dt taOrss iVIATERLIL
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CotttpanyName N R n( :16.INNER CASING'ORTUBING'ebtherma1closed4o
2.Well Construction Permit#: 2 1/— rD - Wt'I)K` y 86 •7 FROM I DIAMETER I TEUCKNESS MATERIAL
List all applicable well construction permits(ie.UIC,County,State,i'ariance eve.) ft. m to
R.
3.Well Use(check well use): ft. in.
11 SCRE,LN` -
Water Supply Well: FROM TO IDIAMETER I SLOTSIZE I THICKNESS I MATERIAL
Agricultural OMunicipal/Public R. R. I is i
_.Geothermal(Heating/Cooling Coolin Supply) Residentral Water Supply(single) -fL !t to
� €! g PP Y) PP Y
Industrial/Commercial Residential Water Supply(shared) I&GROUT
Fln
On FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ter Supply Well: O R. 2t ft.
oring Recovery R• R
n Well: R. fL
rRecharge OGroundwaterRemediation19.St1ND/GRAVELPACK d:a licab[e -
rStomgeandRecovery 08alinityBarrier FROM TO MATERIAL EMPLArsttfErrrMErHOD
Aquifer Test OStormwater Drainage R• ft.Experimental Technology OSubsidence Control fL fL
-- Geothermal(Closed Loop) EiTracer 20:DRILLING LUG attach additional sheets if necessary)
.. Geothermal(Heating/Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIPTION color,turdnw%soillrack mia&by,eta)
4.Date Well(s)Completed:;'iDT�VPell ID#
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5a.Well Location:
„�,s ft. ft.li�
Facility/Owner Name Facility ID#(if applicable) R' fL
ft. fL
ft. ft.
Physical Address.City,and Zip r j� 240 21.REMARKS
County Parcel Identification No.(PIN) � y
[Its*
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36, 15917 N ZT- 9S(2-o W 14_�4 2L
6.Is(are)the well(s) ..Permanent or OTemporary Signaffic of Certified Well Contractor 11 Date
By signing this form.I hereby certify that the vvell(s)teas ptwe)constructed in accordance
1.Is this a repair o an existing well: E3Yes or
No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill at knomn vivil construction informatto and euplain the nan ire of the copy of this record has been provided to the well owner.
repair rider#21 remarks section or on the back of thisform. 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: y 5 (fw) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example-3 tQ200'and 2(Qa 100) construction to the following:
10.Static water level below top of casing: SO 00 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: &h2fty construction to the following:
(Le.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 276994636
i3a.Yield(gpm) 26 Method of test:��!/ 24c•For Water SunDlv-&Injection 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: 67 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 ResourcesRevised 2-22-2016