GW1-2022-00946_Well Construction - GW1_20220107

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZin 14.-WATER ZONES
FROM TO I DESCRITTION
Well Contractor Name IZQ ft. 42t ft 15 ei- n
4518-A ft. it,
NC Well Contractor Certification Number 15:.OUTER-CA SING.'for multi cased=:wells`UR I ITIER :a" "!cable
Aqua Dill, Inc. FROm TO DIAMETER THICKNESS MATERIAL.
ft. ft in.
Company Name / 16:INNER>CASING'UR TUBING.("eothermandosed-loo
2.Well Construction Permit#: 210 FROM TO DIAMETER TIUCKNE55 MATERUIL
List all applicable well construction permits(<.e.UIC,County,State,Variance,etc.) ft' ft in.
ft ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSItE THICKNESS }tlprFnrer.
Agricultural lviunicipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) RfResidential Water Supply(single) ft, ft io.
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
!Irrigation FROM TTOOj MATERTAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft' �6 R 4h f s
Monitoring DRecovery ft• ft.
Injection Well: ft ft
Aquifer Recharge OGroundwater Remediation
::.19:SAND/GRAVEL PACK if:a"licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL. EmPLACEMENT'METHOD
Aquifer Test OStomrwater Drainage ft. tt
Experimental Technology OSubsidence Control ft ft
Geothermal(Closed Loop) OTracer 2o.-DRILLING'LOG attach'additional?sbeets tf ne .
FROM TO DESCRIPTION color,hardness•soi0rock etc.
Geothermal(Heatin Coolin Return) Othcr lain under#21 Remark) FROM
ft. �6 ft
4.Date Well(s)Completed: q 2 Well ID# 12
ft, 223 ft. h�Y
ft. ft
5a.Well Location: n yS'
0olds A�Q h tJ�G ft. ft
Facility/Owner Name Facility M#(if applicable)
ft. ft. i:.l u- •.
-�73 ft. ft JAN 7 2022
S fion r Kra/l P� tab Salk/yam
ft ft
Physical Address,City,ant Zip
21.4EMARICS
County Pamel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification:
3�. 321 n r,� N 90, 659471 W
6.Is(are)the well(s)iVUYermanent or Temporary Signature of'Certified well Contractor Date
T" By signing this form,I hereby certify that the well(s)was(x ere)constructed in accordance
7.Is this a repair to an existing well: J3Yes oroNo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constriction informatioprand explain the nature of the copy of this record has been provided to the well ownm
repair under#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-I 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: 22 S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200•and 2 100) construction to the following.
10.Static water level below top of casing: VO 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: (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
/D,fir y above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: / 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
13s.Yield(gpm) Method of test: CA&Jke 24c.For Water SuDDIv&Iniection 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: 1 I Amount: 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