GW1-2022-07560_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Name S � ft
4518-A
NC Well Contractor Certification Number 15.OUTER CASING(for Tgdgs�wells OR LINER rf a licabli
Aqua Drill,Inc. rROM r0 DFA11rEfER TIICIQQESS MATERIAL
Q ft � ft in.
Comparry Name 16.INNER CASINGdose"
ow)
OR TUBING(eothertnal doseoo
2.Well Construction Permit#: ZuO L oZOa�`'� / FROM TO DIAhlErER IMCENess MATERIAL
List all applicable well construction permits(e.UiG Counth;Sta(e,FarlancA etc) ft ft in.
3.Well Use(checkwell use): ft, ft mL
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE TAICIOIFSS MATERIAL
Agricultural nMunicipal(Public % ft in.
__Geothermal(Heating/Cooling supply) E6Rsidential water supply(single) & ft in.
hrdustrial/Commerdal fOResidential Water Supply(shared)
18.GROUT
'III: tioa FROM I TO MATERIAL EMPLACEMENT METHOD'&AMOUNT
Non-Water Supply Well: (7 ft 2-4. ft
Monitoring ORecoyery ft ft
Injection Well:
3Aquifer Recharge }Groundwater Remediation ft ft
19.Aquifer Storage and Recovery OSalini Barrier FROM ND/GRTOYEL PACK ATERi�AL ry EMPLACEMENT METHOD
Aquifer Test E3Stormwader Drainage fL &
Experimental Technology OSubsidence Control % fL
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG attach additional sheets if necess
Geothermal(Heating/Cooling Return) Mother(explain under 421 Remarks) FROM TO DESCRIPItOry color,bardnts%soNroek n slu,etc.
ft ft
go <Ado-
4.Date Weli(s)Completed: 8�!/f-� Well ID9 020 ft '0 s ft m^ c�
Sa.Well Location: ft ft s ,
Facility/Owucr Name Facility ID#(if applicable) fL
a,�J
ft ft ura
Physical Address,City,and Zit ft. ft In�"rt' �4�OJa
!66 21-REMARKS
County IParcel Identification No.(PIN)
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees:
(if well field,ono lattlong is sufficient) 2L Certification:
36. Y�Y to N '80•62s40 w � ��2z
6.Is(are)the well(s) Permanent or fOTemporary Si ofCerdfi Well Contractor Date
By signing this form,1 hereby certify that the wefl(s)etas(svere)constructed in accordance
7.Is this a repair to an existing well: IYes or o with 15A NCAC 02C.0100 or15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out ktown well construction informatio and explain the nature of the copy of this record has been provided to'the well miner.
repair under#21 remarks section or on the back ofthisfo t. 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 ifnecessary.
wed' SUBMPITAL INSTRIICITONS
9.Total well depth below land surface: 3 yJC (N 249.For All Webs: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdifferent(example-3Q220+0'and 2@1001 construction to the following.
10.Static water level below top of casing: y(O (fL) Division of Water Resources,Information Processing Unit,
Iftvaur level is above casing,roe'+" 1617 Marl Service Center,Raleigh,NC 276994617
11.Borehole diameter. J� _/t_(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.We0 construction method: !O�N�1 above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc construction to the following.
i
Division of Water Resources,:Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: '% 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
13b.Disinfection type: Amount: T627, 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