GW1-2022-03046_Well Construction - GW1_20220228

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZln `14f WATER zONES
FROM 0 DESCRIPTION
Well Contractor Name
4518-A goo �eS It
15& ll-
ft. ft.
NC Well Contractor Certification Number 515:.OUTER CASN .frmult-Casedi0 'OR Sa llcabl
Aqua Drill, Inc. FROM OG DIA It THN
MATERIAL
11 fL 4 ft lin.
Company Name V
t,_p t16:INNER'CASIIVG'ORTQBING "eothe'rmelclosed-loo
2.Well Construction Permit#: 01 ID p FROM TO DIAMETER T•HICXNM MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) n. ft. in.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROM TO DIAMETER '.:....SLOT SIZE THICKNESS I MATERIAL
`-!Agricultural IOMunicipal/Public ft. iG in.
:-)Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) R fL in,
Industrial/Commercial DResidential Water Supply(shared) 18':GRUUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C? ft. V ft. C 4/, Oil"-
_ Monitoring Recovery ft. ft.
Injection Well: fL ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK rf:a litable
Aquifer Storage and Recovery OSalinity Barrier FROM I To MATERIAL. EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control fL fL
Geothermal(Closed Loop) OTracer 20 DRILLING LOG attak'additionkIsheets if necessary):
Geothermal(Heating/Cooling Return) nOther lain under#21 Remarks FROMI TO DESCRIPTION color,hardness,sorUrock in sim,etc.
� ft ,9 ft.
4.Date Well(s)Completed: 2 22- Well ID# ft. 16.5
% N✓
ft. f4
Sa.Well Location: AA/�
7GriGT- of V'-) ft. ft
Facihty/Ownner Name r Facility ID#(if applicable) ft. ft
l V 28 r7`a`.-c L,�em iyl A oo ,yd�e i/�t!i ft. ft.
p
ura
Physical Address,City,and Zip ft. fL Pf 0iR1Q
21:REMARKS... :.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3&' iIS 7`I N 819, 92S y'y W 2
6.Is(are)the well(s)�Permaneut or Temporary
S' / of Certified 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: []Yes or )No with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 WeR Consimcdon Standards and that a
If this is a repair,fill out known well construction informatiod"aannd explain the nation of the copy of this record has been provided to the well owner.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBIYIITTAL INSTRUCTIONS
9.Total well depth below land surface: 16 (fL) 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@1001 construction to the following:
10.Static water level below top of casing: 7� (ft-) Division of Water Resources,Information Processing Unit,
If ureter level is above casing,use"+,. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (m,) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
f1� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(Le.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) �i Method of test: ae ke'N— 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t Amount: 0� 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