GW1-2022-03837_Well Construction - GW1_20220331

Priri Form ,
WELL CONSTRUCTION RECORD(GW-1) For Internal use Only:
1.Well Contractor Information:
Cameron Bazin 14.'WATER'ZONES
FROM I TO DESCRIPTION
Well Contractor Name 0 ft l k s ^
4518-A fL I ft
NC Well Contractor Certification Number 15::OUTER CASING'for multi eased wells
Aqua Drill, Inc. FROM I To D R TMCIGgm MATERIAL
ft. 1 9/0 fL in.
Company Name 3 .
q� �^� '16:INNER CASING'URTOBINGi` 'thermaTiclose0�1
2.Well Construction Permit#: FROM TO DIAMETER TH[CEIVESS MATERIAL
List all applicable well construction permits(u a WC,County,State Parlance etc.) R fL [o.
3.Well Use(check well use): It. ft. ln•
Al SCREEN
Water Supply Well: ]FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. iL in.
Geothermal(Heating(Coolmg Supply) PfResidential Water Supply(single) fL it. in
— Industdal/Commercial Residential Water Supply(shared) --GROUT
F'Aquifer
tion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: Q ft. ft li
itoring Recovery ft. fL
on Well: fL fL
Recharge Groundwater Remediation19:SAND/GRAVEL PACK d:a licsble :fer Storage and Recovery OSalinity Barrier FROM To I MATERUL EMPLACEMENT METHOD
:)Aquifer Test OStornwater Drainage ft. fL
:)Experimental Technology OSubsidence Control % It.
__ Geothermal(Closed Loop) OTracer 20.DR1I LING'LOG attach.additional'sheets4fnecessary)
. Geothermal(Heating/Cooling Return) : Other(explain under#21 Remarks) FROM TO DESCRIPTION cotar,bmtriem mi irock rain dzp,etc.
I 30 ;A010
fL
4.Date Well(s)Completed: 3 1,/ZZ Rreu ED# , ftt JT ft.
ft. ft.
5a.Well Location:
A41A ��to
ft fL
Facility/Owner Name Facility ID#(if applicable) ft. ft
i \ d
AD5 t�� fl G t7i f d. 1ho�kSrt/lc,/YG fL ft. MAR 3
Physical Address,City,and Zip
IF It. fL
dt1�G 21-REMARKS
County Parcel identification No.(PIN) ) '
w•'i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
3 S. 9ffl7 N SO, 520b8 W
Signature of Certified Well Contractor Date
6.Is(are)the wells) ..Permanent or �ITemporary f
By signing this forms,I hereby certify that the tvell(s)was(were)constructed in accordance
1.Is this a repair to an existing well: 1Yes or _ No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeR Construction Standards and that a
If this is a repair,fell out known well construction infosnatio and explain the nature of the roP1'ofthis record has been provided to the rrell atvner.
repair under#21 rounds section or on the back of this fo 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: L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: '7 S (ffi) 24a.For All Wells: Submit this foma within 30 days of completion of well _
For multiple wells list all depths ifdifferent(example-3@200 and 1Q100� construction to the following'
10.Static water level below top of casing: l7 (k) Division of Water Resources,Information Processing Unit,
If ureter level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter. 24b.For Injection Wells: In addition to sending the form t0 the address III 24a
above,also submit one copy of this'form within 30 days of completion of well
12.Well construction method: f m N!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
13a.Yield(gpm) 30Method of test: l 24c.For Water SunDly&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: J90= 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