GW1-2022-01897_Well Construction - GW1_20220210

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Cameron Bazin IL WATER 7gN�5 _
FROM TO DI:aCRwncii
Well Contractor Name
� t, ft. �25_toPRI,
451 B-A rt fNC Wc0 Contractor Certifiation Numlw is•OUrT R CASING for tataNisned ntMWMR U hk�Aqua Drill, Inc. FROM To DIAMr= KNM MATERIAL
L ft. U n. G Ia
Company Name c 7 16.MER CASINO OIt TUBING do
FROM TU DIAMRTCN
ru TNt(7tNrbS MAT[AIAL
2.Well Constcti p J7/on Permit q: ft n t�
.girt all applicable xrli nautructutn permits(Le.Ultra Cowary,State.Variance,dc.J _ .
3.Well Use(check well use): _
Water Supply Well: FROM R io DtAMETEa sir DT SIM THICKNAL" MA
TERIAL
Agricultural []Municipal/Public tt. rt. In.
Grntbetmal(icatingfCooling Supply) olkesidential Water Supply(single) ft. ft
lndustriaVCommerclal 12Residential Water Supply(shared) IS.GROUT —
lrri anon FROM TO MATERIAL_ tutrh AcrAnxr METHOD A AMOt1Kr
Non-Water Supply Well: ft- 2 H' G lT% — ` vrt'J_
Monitonng DRecovery ft. tt.
Injection Well: rt fL —
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicab►a,- EMPLACEMYNr METHOD
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL—
Aquifer Test OStormwater Drainage rt. R.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets it aecesary)
FROM TO DFSCRIPTIDN(rnbr Oatdaw•saalreek type. �•etc
Geothermal(-leating"Coolin Return)) Othcr(explain under 421 Remarks) Q ft. S� ft LQ�
4.Date Well(s)Completed: ' �q 2 2- Well ID# ft' ,G 7 /
ft, ft.
5n.Well Location: —
ft. n.
Facility,'Owner Name Facility ID#(if
rta C ram-1 �L f[. ft
4- 5 —
rt. ft.
Pbysa at�ddress,City,and zip —
21.REMARKS
Cauaty Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(irwell field,one laviong is sufficient) 22.Certification:
N go, 22., W _ _ y-
Signe of Cent ell Contractor D
6.Is(are)the weU(s) ermaneot or Temporary
By signing this form,!hereby certify the.:'the xrll(s)was(xrre)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeLI Construction Standards and that a
7.Is this a repair to an existing well: ®Yes or o cap)-o this record has been rovided to tie well owner.
g1his is a repair..fdl aut bto»n we11 construction information nd explain the nature of the p5 f p
repair under#21 remarks section or on the back of thu form. 23.Site diagram or additional well details:
Geothermal Wells having the same You may use the back of this page:o:provide additional well site details or well
8•For GeoprobwDPT or Closed-LOOP construction details. You may also attar h additional pages if necessary.
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
SUBMITTAL INSTRUCTIONS
drilled:_9.
depth below land surface: (n•) 24a. For All Wells: Submit this form within 30 days of completion of well
For oral well,Us Uri all depths jdi,(ferent mple-3C�00•and 2@1 ff) construction to the following:
J U (n.) Division of Water Resources,Information Processing Unit,
10•Stalfc water level below top of casing: 1617 Mal!Service Center,Raleigh,NC 27699-1617
if»ores Lev,u above easing,use"+
(in,) 24b.For Injection Wells: In addition to sending the fort to the address in 24a
11.Borehole diameter: above,also subunit one copy of this r,'onn within 30 days of completion of well
(O$Gt(�/ construction to the following:
12.Well cons>n�°°°1��(ie.auger,rotary.table.direct push.etc•) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY: Ci 24c.For Water S4DDly&Iniectio_,,Wells: In addition to sending the form to
Method of test: the address(es) above, also submit one copy of this form within 30 days of
13s.Yield(gpm) �,. _ completion of well construction to the county health department of the county
Amount:- � where constructed.
13b.Disinfection type:
North Carolina Department of Environmental Quality-Division of Water Rtsouitcet Revised 2-22-2016
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