GW1-2022-04872_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
i
Cameron Bazin 14.WATMZONM..
FROM I TO DESCRiPTLONI Well ContraetorName ft• {t
4518-A ft. ft
NC Well Contractor Certification Number IS:OUTER.CASINGformulti-casedtvells ORLQQER rfa liraliie
Aqua Drill, Inc. FR 'M To DIAMETER TL1[CKNESS MATERIAL
ft. fib It in.
Company Name 46.INNER CASING'OR TIIBING 'ebthermalclosed-ldo
2.Well Construction Permit#: FROM TO DIAMETER � TLrICE(NESS MATERIAL
List all applicable hell constructionpermits Ae-UIC,Colin%State,Lrarlance,etc-) ft. fG m.
ft. ft. in•
3.Well Use(check well use):
17.sCREEN•.'
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS 1fATERIAI
Agricultural fOMunicipaUPublic ft, ft.
Geothermal(Heating(Cooling Supply) DResidential Water Supply(single) ft ft in
Industrial/Commercial DResidential Water Supply(shared) I&GROUT
llll aLiOri FROM TO MATERIAL EMPI.ACEMENTMEMOD&AMOUNT
Non-Water Supply Well: 0ft. 2( .ft
Monitoring ORecovery n. ft
Injection Well: it ft.
Aquifer Recharge QlGroundwaterRemediation 19.SAND/GRAVEL PACK rf.a licsble .
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I EMPL.ACEMENTMECHOD
Aquifer Test DStormwaterDrainage ft. ft
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DAM ING LOG attach additional sheet-if necessary)
Geothermal(Heating/Cooling Return) Othcr(explain under 921 Remarks) Fi
To DEsctuPrloN rotor,azraaess sviurack g rate ffio etal
a ft
4.Date Well(s)Completed: r7 Virell 1D# ft.
ft
5a.Well Location:
Arm^ 4�'� ft
%
FaciGtyOiKvacrrNam /JV� Facility ID#(ifapplicable) ft• ft
ft ft
pD i tl •Ids Of ft
Physical Address,City,and Zip
X
(&k�^ 2L REMARKS
County 1N� Parcel Identification'To.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: vt:.;,F ,I^.� • %
(fwellfield,one lattlongissufficient) 22.Certification: y tf'"�Il�f•.. ��
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Connector Da
By signing lit is form,I hereby cergry that the wells)Was(were)constructed in accordance
7.Is this a repair to an existing well: nYes A.Maindiena
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constniction Standards and that a
Ifthis is a repair,fill out knotm well construction inform.. urre of the copy ofthis record has been provided 10 the well mvner.
repair under#21 rimiarks section or on the back ofthisform, 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled: nn SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3`S (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For mahipto wells bast all depths ifd8erent(example-3@200'and 2@100) construction to the following.
10-Static water level below top of casing: So (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: _Gn•) 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
12.Well construction method: construction to the following:
(Le.auger,rotary,cable,direct push,rtc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
t
13a.Yield(gy Im) ` 5 Method of test. l� 24c.For Water Sunuly-&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: �/�� completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016