GW1-2022-03008_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZln 14:,WATER'ZONES
FROM TO DESCRIMON
Well Contractor Name
4 `ft- 3v
518-A 5 ft a'G
ft. iz
NC Well Contractor Certification Number I&DUTER CASING'for molts cased:wells"OR I INER' a""hcable
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIAL
ft. ft.
Company Name
�23 16:INNER CASING-OR TOBING "etitbermallclosed-ldo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft n- In.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17SCREEN
PP Y FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural I31viunicipal/Public ft. ft in.
Geothermal(Heating(Cooling Supply) PIResidential Water Supply(single) R IL in.
Industrial/Commercial bResidential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. It. l7U42
Monitoring ORecovery ft. ft.
Injection Well: FL ft.
_'Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK f a ticable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology [ISubsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRILLING LOG attach Additional sheets;If ne
Geothermal(Heating/Cooling Retum) FlOther(explain under#21 Remarks FROM To DESCRIPTION color,hardness,soiltrock type,Fmin si7A eta
O ft. O ft. ✓zA
4.Date Well(s)Completed:V&L Well ID# & % N 1 Pr
ft, it.
5a.Well Location: y
�_loi7J�'c�n fr. sc
Facility/Own ame Facility ID#(if applicable) ft. ft.
38 Fa(-- t1- 61_49 soar, ft. ft
Physical Address,City,and Zip
�" ft. It. FEB 2 8 2022
fry 21.REMARKS-:. '.._ V .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well/field,one lat/long is sufficient) p / 22.Certitication:
t'V(191 N O r (O W
6.Is(are)the well Permanent or Temporary Signam ed Well Contractor Date(
By signing this form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ryes or No with 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
lfthis is a repair,fill out known well construction information/�,d explain the nature of the copy of this record has been provided to the well owner.
repair snider#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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: L SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (N 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100) construction to the following.
10.Static water level below top of casing: S (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
A�1/ above,also submit one copy of this form within 30 days of completion of well
�O
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 276994636
13a.Yield(gpm) Method of test: 24c.For Water Sum&&Iniection 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: /��'7 completion of well construction io the county health department of the county
when constructed.
i
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources