GW1-2022-05957_Well Construction - GW1_20220615

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WELL CONSTRUCTION RECORD(GW4) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well ComractarName FROM TO DESCRIPTION
4518-A bs
ft
it. ft.
NC Well Contractor Certification Number 15.OUTER CASING formalti-cased wells PRUNER if a liwble
Aqua Drill, Inc. MOM TO DIAMMIR TfUCKNESS MATERIAL
O ft. 15 ft in
Compa�rName
VMS
16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#: (� /( FROM To DUD ETER I THICKNESS MATERIAL
List all applicable well construction permits(.e.GIC,Cormt},State,Variance,eta) M M in.
3.Well Use(check well use): ft, ft in.
Water Supply Well: 17.SCREEN
FROM TO DTAMETER SLOTSIZE THICKNESS MATERTAL
Agricultural DMutticipaUPublic ft t in.
Geothermal(Heating/COoling Supply) Residential Water Supply(single)
IndustriablCommemial DResidential Water Supply(shared) is.GROUT
lHgation FROM I To MATERIAL EMNACEMDUMEMOD&AMOUNT
Non-Water Supply Well: O ft. Z It.
Monitoring 011ecovery a. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGromidwaterRemediation
19.SAND/GRAVEL PACK rif anuticablel
Aquifer Storage and Recovery DSallnityBarxier FROM TO MATERIAL EMPLACEMENTMMOD
-Aquifer Test OStormwater Drainage fL fL
Experimental Technology [3SubsidenceControl ft ft
Geothermal(Closed Loop) OTMer 20.DRII LING LOG attach additional sheets if neces
Geothermal(Reating(Cooling Retain) r10ther(explain under#21 Remarks) FROMI To DESCRI MON(color,hardness,sollfrockrype,grain sirs,etc.)
fL.
4.Date Wells)Completed: Well M# 20 ft, �ys R'
5a.Well Location: H' ft.
n ft
Facility/ChZrNamc Facility ID#(ifapplicable) R- ft. _
Physical,Address,City,and Zip i� R J UPJ I ,)
2L REMARKS
County Parcel Identification No-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: � � yai] rra�t 3�I s °- 1 tl`ir
(if welt field,one latAong is sufficient) -' '
D �c 22.Certification:
7K. 5 N O� y�I W �� !;
6.Is(are)the weD(s)�ermanent or Temporary Signamm�C�ified Well ntractor ` Dawt
�� By signing this form,I hereby certify that the wells)ivas(were)constructed in accordance
7.Is this a repair to an existing well: DYes or NO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 WeB Construction Standards and that a
'this is a repair,fill out btoum well construction informati and erplain the nature of the ropy ofthis record has beers provided io the well owner.
repair under#2I remarks section or on the back of tlds 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 ifneccssary.
drilled:
SUBMITPAL INSTRUCTIONS
9.Total well depth below land surface: LI S (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For malt ple wells list aR depths##-different(example-3@200'and 2@I001 construction to the following
10.Static water level below top of casing: 7 o (ft) Division of Water Resources,Information Processing Unit,
Ifuater level is above casing,Lire"+" 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
12.Well construction method: �(� ry above,also submit one copy of this farm within 30 days of completion of well
(i.e.auger,rotary,cable,dheetpush,etc.) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: Y 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) O Metbod of test: 7r lt� 24c.For Water Supply&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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016