GW1-2022-03093_Well Construction - GW1_20220307

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZln 1C WATER'ZONES'.
FROM I TO DESCRIPTION
Well Contractor Name /ro It r S fL f�1
4518-A 1 n, % ` 7
NC Well Contractor Certification Number 15:OU.. .CASING 06i mulfl-cesed;ivells'OR I:INER'tf a licatiie a'.:r' _`t '•.;:
Aqua D611, Inc. FROM ft To DIA R in. T aCKNESS I MATERIAL
fL
Company Name �f 'J/' Q 16.INNER CASSIING"OR TUBING: '.thermal closedaoo
2.Well Construction Permit#: `�— �t/',V�r,`�� FROM TO DER TmCiavEssI MATFRML
List all applicable well construction permits ii e.U! ,County,State,Irariance,etc.) ft. ft• in.
ft. in.
3.Well Use(cbeck well use): ft.
17.SCREEN';`
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL i
Agricultural MunicipaUPublic ft. fL in.,
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) ft, IL
Industrial/Commercial AResidential Water Supply(shared) 18 GROUT
Irri ation FROM TO MATERIAL EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: ft' ft. G
Monitoring DRecovery ft• ft
Injection Welt., ft, ft.
Aquifer Recharge 00roundwater Remediation
19.SAND/GRAVELPAOC s itcable .
Aquifer Storage and Recovery DSalinity Barrier FROM To I MATERIAL EMPLACEMENrMEMOD
Aquifer Test [)Stormwater Drainage ft. ft.
_..Experimental Technology OSubsidence Control fL fL
Geothermal(Closed Loop) ©ITmoer 20.DRILLING'LOG attach.additiodal sheets'ifnecessary)
FROM To DEscRlrr►oN
Geothermal(Heating/Coolin Return) Other( lain under#21 Remark) rotor,haraars�soiuraetc rata ser elm it. SAD it.
4.Date Well(s)Completed: Z 23 Z2. Well Ma S n
ft. fL
Sa.Well Location:
ft. it.
Facility/Owner Name Facility iD#(if appGeolee)r� ft' ft' RFr -
{'•t �'f'it� l tlt Gl1bd! ft. ft.
% ft.
Physical Address,City,and Zip
1 fFodd, zl REMARKS.'
County Panel Identification No.(PIN) lift t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification:
`3G• K99-7 N ?9 K"I W ��. 2 Zg 2�
6.Is(are)the well(s)RfPermanent or OTemporary Signature of Certified Well Contractor Date
/�— By signing this fort,I hereby certify that the tvell(s)was(were)constructed in accordance
1.Is this a repair to an existing well: OYes or 'ONo Wth ISA NCAC 02C.0100 or iSA NCAC 02C•.0100 Well Construction Standards and that a
If this is a repah,fell out knoum well construction informatfo td explain the nature of the coPy ofthis record has been provided to the well owner.
repair under#21 remarks section or on:the back of this farm. 23.Site diagram or additional well details:
S.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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: o C SUBMITTAL INSTRUCTIONS'
9.Total well depth below land surface: 185 J —(ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple we&list all depths if different(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: 7 O uo Division of Water Resources,Information Processing Unit,
Ifnvaterlevel 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
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method- / a m& _ 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 Marl Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) 15 Method of test 14C ke r 24c.For Water SunDlv•&Infection 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 completion of well construction to the county health department of the county
where constructed.
i
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016