GW1-2022-04141_Well Construction - GW1_20220425

WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin
14:wATERzoNE3-..
FROM 1 O DESCRIPTION
Well Contractor Name es,,, ft S ft
4518-A 1� ft, ft
NC Well Contractor Certification Number 15;OUTER.CASING' ormulti-cased-ivells'ORI:INER rfa lithlite:--:'
Aqua Drill, Inc. FROM I TO DIAMETER in. THICKNESS MATERIAL
Company Name 36.INNER CASING ORTIM ( ebthermalcidsed-1oo
ar
FROM TO DIMfETEtt THICKNESS eTc�Rrnr.
2.Well Construction Permit#: - n, � In.
List all applicable well construction permits(e.UIC,Counev,State,flariance,eta)
ft 3.Well Use(check well use): ft. in.
17.SCREEN
Water Supply Well: FROM I TO D[AMErER SLOT slzE TltfcKNEss MATERIAL
Agricultural DMunicipal/Public ft. ft
__
Geothermal(Heatingicooling supply) [!,�IResidential Water Supply(single) ft fit Io
_ Industrial/Commercial DResidential Water Supply(shared) . lti.GROUT
...Irri ation FROM TO MATERIAL EMPLACF.MENTMETHOD&AMOUNT
Non-Water Supply Well: [t ft
Monitoring DRecovery M ft
Injection Well:
AquiferRecbarge oGroundwaterRemediation 19.SAND/GRAVEL PACK .a liwble .
Aquifer Storage and Recovery oSaliniry Barrier FROM TO MATERIAL EtvIpLACERtENT METHOD
_- Aquifer Test Ostormwater Drainage M ft
Experimental Technology OSubsidence Control R• ft
Geothermal(Closed Loop) ©ITmcer 20.DRIId1NGLOG attach additional sheets if necessa
FROM TO DESCLtIPrION rntnr hardness.soi0rorh e, nix six,ela
[.Geothermal(Heating/Cooling Return) Olhcr(explain under#21 Remarks) ft. ft
4.Date Well(s)Completed: L-~ Well]OW" f19 t
ft tt _
5a.Well Location: ft. it R. r' ,I a i -
pale - �,:a(v�5 ft. ft � z
Facility/Owner Name / Facility IDR(if applicable)
deft `2 ,' ft ft -
Physical Address.City,add Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cifwell field,one lat/long is sufficient) 22.Certification:
`'39 36(yo N �o.. -385go W zytef= �/ z
6.Is(are)the well(s) Permanent or OTemporary
Signature of rtified Well Contractor Date
to By signing this foray,I hereby certify that the uvell(s)was(woe)constructed in accordance
1.Is this a repair to an existing well: 3Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ijtluls is a repair fill out knoxm rhe11 rnrrstrrction injornatio lain the nrirure of the �Pl'oflhis record has been provided to the uve11 mumer.
repair under 01 rvmarkr section or an die 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 TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMI ITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fd fferent(example.3@200-and 2Q1005 construction to the following'
10.Static water level below top of casing: Jb (ft) Division of Water Resources,Information Processing Unit,
Ijrvater level is above casing.rose"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. 49� (in•) 24b.For Iniection 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
P
12.Well construction method: �Of construction to the following
CLe.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
13s.Yield(gpm) Method of test: A!/�Jtl 24c.For Water SunDiv-&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: G6L 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 Waler Resouuces Revised 2-22-2016