GW1--03135_Well Construction - GW1_20230505

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A 2�'S ft ft, 3 ( Ti'l l
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(tf ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0ft. 4'c ft . in. ir�(�
Company Name ti .
/�'� (0/� 16.INNER CASING OR TUBING(geothermal closed-loop)
(71 2.Well Construction Permit#: 1 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction pemtits(i.e.UIC,Cormt)t State,Variance,etc) ' ft in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
FROM TO
ft.
DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public It. in.
Geothermal(Heating/Cooling Supply) tResidential Water Supply(single) ft. in
Industrial/Commercial Residential Water Supply(shared) IS.GROUT ,
IrrigationFROM TD MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,. D- 2 ft L/ii 10
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
'Aquifer-Recharge Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Bawer FROM TO i MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft
Experimental TechnologySubsidence Control IL ft
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets it necessary)
Geothermal(Heating/Cooling Return) IQther(explain under#21 Remarks) FROM TO DESP,17N((color,hardness,soil/rock type,grain size.etc.)
0 fr. .h ft !y«t„CTkTc
4.Date Well(s)Completed: / j2.7 Well ID# s'r ft- ,2 ft- 16`4,-
5a.Well Location: ft ft �1,.,.-, 'E v A0„....fr. ft.Flit((; q), ` 140(
Facility/Owner Nadie Facility ills(if applicable) ft. n. MAY 0 5 2023
�7 - ft. ft.
Physical Address,City,and Zip rr�rtiT
t 1ft. ft I fl#Cri ti,":f' I. a'�.:
.t it3 '1+
' t Vitr1`/ 21.REMARKS _
County f Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field...one lat/long is sufficient) 2?Certification:
£i 3C ' '
6.Is(are)the wells) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certfy'that the well(s)twos(were)constructed in accordance
7.Is this a repair to an existing well: ',OYes or o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a rerralr,fill out lators well construction informoti and explain 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 farm. 23.Site diagram or additional well details:
I.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: 3 5 (f-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3� 00'and 2Q100') construction to the following:
10.Static water level below top of casing: yr (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 Injection 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: (b W�1%
(i.e.auger,rolaty,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16%
.7
13a.Yield(gpm) ...) Method of test: 1 G r/-L,two 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(et) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /ft Amount i ,-,c . completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016