GW1-2022-02892_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin la:-wnTERzolvEs _
FROM TO DESCRIPTION
Well Contractor Name IL
S ft.
17.1
4518-A it. ft
NC Well Contractor Certification Number o 15ii0UTERiCASIN U for.mnlH-casedwells`OR>I:MR' :ii"'"bcable
Aqua Drill, Inc. FROM T DlatuIETER THICKNESS hfATERW
Q ft. o ft �j m•
Company Name
16'1NNER`CASING'UR TUBING: eothermehdosed loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Parlance,etc) ft. ft.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17 SCREEN '
PP Y LrR'OMDI TO AMETER SLOT SIM THICKNESSAgricultural IOMunicipaUPublic ft. % in-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. & in.Industrial/Commeroial Residential Water Supply(shared) °GROUTIrri ation OM r�TO MATERIAL EMPLACEMENT METHOD&AMOUNT_
Non-Water Supply Well: f. 2 ft Gti 1
Monitoring ORecovery ft. ft
_ -- lnjection wen:------------ ft. ft
Aquifer Recharge E3Groundwater Remediation
z.,19.,.SAND/GRAVELPACK--fifagpHvable
I Aquifer Storage and Recovery 08alinity Barrier FROM ft. it.To MATERIAL
I EMPLACEMENT METHOD
_Aquifer Test [3 Stomrwater Drainage
Experimental Technology [ISubsidence Control ft ft
Geothermal(Closed Loop) OTracer 20 DRILLING'LUG attach additionalsheetsifnecess
Geothermal(Heating/Cooling Return) Other lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock in sirr,etc
4.Date Well(s)Completed:2 `/ ZZ Well iD# ft. ft J
ft. ft
5a.Well Location:
ft. fL
Facility/Ownd Name Facility ID#(if applicable) ft. ft.
�1>ro�L 6& ft. ft
Physical Address,City,and Zip
�f srf� 21.:REMARKS.: kJ&)N&Wkn'P'r0C0GW4 URN
1DWOROG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification:
76. 11174 N o• Yv194
6.Is(are)the well(s _ ermanent or Temporary Sig of CeRified Well Contractor Date
By signing this form.I hereby certify thattthe wells)was(were)constructed in accordance
7.Is this a rep to an existing well: Yes or No with 1 SA NCAC 02C.0100 or 15A NCAC O2C.0200 Well Construction Standards and that a
jthis is a repair,fill out known well construction informatioanndd explain the nature of the copy of this record has been provided to the well owner.
repair under#21 ronarAs 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 details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed Indicate TOTAL NUMBER of wells
drilled: p SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 6 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(ur)200'and 2@100) construction to the following:
10.Static water level below top of casing: �0 (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: (n 24b.For Infection 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: a `4-n/ 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) d 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: Tly - 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