GW1-2022-03015_Well Construction - GW1_20220228

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w�LL CONSTRUCTION I�CORD(GW-1 _
!'Well Contractor war—don: 14,WATLY ZON68
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Cameron Bazin
Wcll Contractor Norm fL
fL a ble
45 1 8-A CtR LiNIiR MATyIty L
13. yQ CAgptG for D Tin
NC'W'11C-ntrncto,cert{6atooNum6er PfrOM TO Is
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Aqua Drill, Inc. lrtilxrr�scAslrtooRive � HA AL
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COmPanY Name PROM TO to
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ell Construction Permit#: r�C� Srate,Variance,et ) ft lo.
nplicable Hell camrrmcrion permits(Le.U1C,Cowry• fL ft.
3•Well DIAMaTPa TNICKNLBS MAT6alAL
Use(check well use): 17.SCR66N &,o•r�
Water Supply Well: PROM ft TO ft In.
Agricultural a MunicipaUPublic ft is
fL _
�Oiheirnal(Healing/Cooling Supply) esidennal Water Supply(single) _ MeffOD i AMOL—
IndustriaVCommercial /a Residential Water Supply(shared) 1&GROtfr MAT ERUL RMri ALZJrf�r
_
PROM TO
Irri anon b ft. 3 ft G4 _ �
Noa-Vyater SupptY Well: ft IL
Monitorin8 Recovery
Injection Well: t;- ft.
Aquifer Recharge 13Groundwater Remedistion 19.SAND/GRAVEL PACK a tlable_ gKrLACzMENT NKMO13
aStormwater Drainage TO MATERIAL _
Aquifer Storage and Recovery []SalinitySalinity Baer ft.
Aquifer Test ft• —
Experimental Technology Subsidence Control
GeotherIDal(Closed Loop) Tracer FROM
DRILLING LOG attach Dddi'onallO eat et.
FROM 70
Geothermal(Heatin Conlin Rehr_) Other( lain under#21 Remarks tt tt
4.Date Wdi(s)Completed: Well ID#
ft. ft.
5a.Well Location:
In V
Facility/07,ifier Name Facility I)#(if applicable) _
/tea/l� of lt-„ Seal 1d12/� ft. fL -
— tt.Physical Address, ft
,and Zip —
U�t 1 J,a 21.REMARKS —
County /[ Parcel Identification No.(PIN) —
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
DMfWOG
(if well field,one tar/lang is sufficient) 22.Certification:
3t6 3 f,2 W
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6-Is(are)the well(s) ermanent or Temporary
Signature of Certifie ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7 Is this a repair to an existing well: ayes or No will I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out brown wte//construction informatio and explain the native of the copy of this r•ecard has been provided to the.vr-l/owner.
repair under#21 remarAN section or on the back of this form. 23.Site diagt itm or additional well details:
Geothermal Wells Navin the same You may use the back of this page to provide additional well site details or well
8.For GeoprobelDPT or Cloned-Loop 8 construction details. You may also avaoh additional pages if necessary.
construction,only I GW-I is needed- indicate TOTAL NUMBER of wells
dnDed: SUBMITTAL INSTRUCTIONS
wdl depth below land surface: �� (ft) 24a. For All We]s: Submit this !oral within 30 der
9.Ttrtal I di 8erent(example-3@200 ad I®I00) construction to the following: days of completion of well
For nrultlple wells
list all depths f
level bebw top of casing: (ft) Division of Water Resources,Information Processing Unit,
If Stine 1617 Mail Service Center,Raleigh,NC 276"-1617
neater/ew;l i+above casing use„+..
11.Borehole diameter On.) r Infectio
tr 24b.Fon Wells: in addition to sending the form to the address in 24a
above,also submit one co of thin farm within 30 der
construction the following: Ys of completion of Well
12-Well construction Me
dc.)
(Le,auger,rotary,cable'doer P Division of Water Resources,C oiler
ground
FOR WATER SUPPLY WEB
ONLY: 1636 Mail Service Center, aleigh,NC 27694 163eCtion 6 Program,
Method of test: 24c.F r Watwr SuoDly. Ini N,
13a.yield gym) �t j--ZL the addresses) above, also submit one co
(/ / /� 2e ells: In addition to Sending
Amount: ZZ' completion of well construction tc Ole eoun the forth to
where constructed PY of this form within 30 days of
13b.
Disinfection type• heal Nth department North Carolina Department of Environmental Quality of the county
-Division Water
Form GW-1 Resources
Revised 2-22-2016