GW1-2022-06066_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD(GW 4) For Internal Use Only:
L Wetf Contractor information:
Cameron Bazin U.WATERZONES'.
Well Contractor Name FRO��%1 TO DESCRIPTION
G� ft- Wb ft S
4518-A !/D
ft. ft
NC Well contractor certification Number MOUTE1t.CASING'formulti-�se3lvclls"ORIINER(ifa Qealile •'
Aqua Drill,.Inc. FROM To DIAtvIEfER THICKNESS MATERIAL
tt. 10 ft- In.
CompanyName
Q ,16.INNER CASING ORT(TBING(ebthermal closed-Ioo
2.Well Construction Permit r'l: �'^ 7Z FROM TO DIAMETER THICKNESS MATERIAL
List all applicable irell cons(rurlion permits(i.e.VIC,County,State,4arianm etc) K- fL in.
3.Well Use(check well use): ft ft is
Water Supply Wells 17.SCREEN'
FROM I TO DIAMETER SLOT SIZE THICKNESS NTATERIAL
Agricultural DMunicipal/Public ft. ft in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft it-
Industrial/Commercial f[(Residential Water Supply(shared) I&GROUT
Irrigation FRONT TO MATERIAL ENTPLACEMENTMErROD&AMOUNT
Non-Water Supply Wes= O R' 'R- �
Monitoring ORecovery ft. ft
Nectibn Well:
[t. ft
quifer Recharge DGmundwaterRemediation
19.SAND/GRAVEL PACK rf a licabie .
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERLkL EMPLACEMENTMETHOD
Aquifer Test 08tormwaterDrainage R• ft.
Experimental Technology OSubsidence Control ft• ft.
Geothermal(Closed Loop) DTmcer 20.DRiLIMGLOG attach additional sheets ifnecessa
FROM TO DESCRIPTION(color,hardness.soiltroek e, ruin saq elm)
Geothermal(IieatinJCoolingneturn) Other(explain underR21 Remarks) <D ft.. .1, ft y,W2
4.Date Well(s)Completed: �7 LZ Well 1DR Ft. e3o %
5a.Well Location: 2 It
ft R
Facility/Owner ame Facility ID@(ifapplicable) ft ft
tU544� Ck .(,1. Qirllrtx.fOJ .
Physical Address,City,and Zip ft. fL
4�t�' 21.RF. URICS t
County ip Parcel IdentiricationNo.(PIN)
Sb.Latitude and longitude in deb ees/minutes/seconds or decimal degrees:
(ifwellfield one iaUlonoissuf'ncient) APT: i `'`"'"
22.Certification:
Z�2.gv N OO V 3111 W
6.Is(are)the well(S) ermartent or `.,Temporary Signafaire of Certified Well Contractor Date
By signing tleis farnt,I hereby certify that the ivell(s)was(uae)constructed in accordance
7.Is this a repair to an existing well: DYes or No wide ISA NCAC 02C_0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifdds is a repair,fell outhnoaa well construction infonnatlon&d erplain die nature of the copy ofthis record has been provided to the we11 owner.
repair under 01 irinarks section m•on the bacL-of rhisfomi. 23.Site diagram or additional well details:
8.For Gcoprobe/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 OW-1 is needed. Indicate TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL 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 fist all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of rasing: 50 (ft.) Division of Water Resources,Information Processing Unit
If water level is above casing tee'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Iniection Wells: In addition to sending the fonv to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: COW construction to the following:
(i.e.auger,rotary,cable,directpuusb,ctc_)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: er� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method of tests � tiY 24c.For Water SuDDIv•&Injection 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: 00 Z completion of well construction to time county health department of the county
where constructed.
Farm GW-1 North Carolina Department ofEavironmental Quality-Division of Water Resources Revised 2 22 2016