GW1-2022-06057_Well Construction - GW1_20220629

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WELL CONSTRUCTION RECORD(GW-1) For latemal Use Only_
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
fL
4518-A 3' ft Y 6
ft: ft.
NC Well Contractor CertificationNrmrber 15.OUTERCASING for multi cased wells OR LINER if a livable)
Aqua Drill,Inc. FRoM To DIAa R TmQINES3 Me)
CompanyName
0 ft 0 ft in.
16.1NN1•;R CASING ORTUBING(eothermal closed loop)
2.Well Construction Permit#• ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(I.e.UIC,Count};State,Parlance,eta) ft. ft in.
3.Well Use(check well are):
ft. it. in.
Water Supply Well: FROK SCREEN
TO DIAMETER SLOT SIB TmCKNFSS MATERIAL
Agricultural DMunicipal/Public ft iti in
Geothermal(Heating(Cooling Supply) OResidential Water Supply(single) ft. in.
Industrial/Commercial lDResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well- IL s iL
Monitoring ORecovery ft ft
Injection Well. ft. ft.
F. Aquifer Recharge OGroundwaterRemediation
Aquifer Storage and Recovery DSalinity Barrier FROK GRTO AVEL PACK>MATERavolicIAL
EMPLACEMEKr METHOD
Aquifer Test OStotmwater Drainage It. fL
Experimental Technology OSubsidence Control ft. %
Geothermal(Closed Loop) F3TIacer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Aeating/Cooling Return) Mother(explain under#21 Remarks) FftL
TO DESCRIPTION color.bardness,saturock a size,etc.)
?o ft4.Date Well(s)Completed: WellID# it5a.Weil`Location: ft
Facility/Gw Name Facility MH(ifapplicabie) fL
�.i/GSn� •�ab�>� �lee►�ill�G fr_ . ft
Physical address,City,and z ft. iz JUN 2 9 ZOE
7 21.REMARKS
L ri
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/miauteslseconds or decimal degrees:
(if wcU field,one latllong is sufficient) 22.Certification:
6.Is(are)the well(,) Permanent or Temporary Signature of'Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: lDYes or ON. with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formatio mid explain the nature of the copy ofthis record has been provided io the well owner.
repair under 021 remarks section or an the back ofthisform. 23.Site diagram or additional well detw1s•
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 ifnecessary.
dri SUBM TTAL INSTRUCTIONS
9.Total well depth below land surface: IV 00. 24a.For All Wells: Submit this form within 30 days of completion of well
For maniple wells list all depths ifd8erent(example-3 200'and 2Qa 100) Construction to the following:
10.Static water level below top of casing: d (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection 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: tf D tQ4-�f construction to the following:
(Le.auge,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
13a.Yield(gpm) Method of test 24r-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 WaterResources Revised 2-22-2016