GW1-2022-06067_Well Construction - GW1_20220629

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A s ft. n
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER rf a licable
Aqua Drill,Inc. FROM To DD311TER THICKNESS MATERIAL
fG in
Company Name 70 ft.
t' 16.INNER CASING OR TUBING(geothermal closed-loop)
2. IA
WellConstructionPermit#. �YS� FROaf TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits C.e.UIC,County,State,Parlance,etc.) ft. ft. in.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
FRONT TO DIAMETER SLOTSIZE THICKNESS MATERIAL
_-.Agricultural DMunicipal/Public ft % in.
Geothermal(Iieating/Cooling.Supply) Residential Water Supply(single) ft. in,
IndWtrial/Commercial OResidential Water Supply(Shared)
_ 18.GROUT
hri ation FROM I TO MATERIAL EMPLACEMENT MEI{{OD&AI1fOUN-r
Non-Water Supply Well: 40 ' ft G4A of
Monitoring Recovery ft. ft.
Injection well: ft, ft.
Aquifer Recharge DGronndwater Remediation
19.SAND/GRAVI:LPACK ifs livable
Aquifer Storage and Recovery OSallnity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
tAquiferTest 0StormwaterDrainage fL fh
Experimental Technology OSubsidence Control ft. It
RGeothermal(Closed Loop) DTracer 20.1) LING LOG attach additional sheets if necessary)
Geothermal(Reating(Cooling Return) —other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,satUrock a rain sire,eta
/� tt fL
4.Date Well(s)Completed:_� ! Well ID# R rj ft-
5a.Well Location: fL ft.
t2 ft
Facility/Owner Name R Facility ID#(ifapplicable)
fL ft. q"C ,y r
Y/116 ft. ft. � 2 9 -
Physical Address,City,and Zip
it rr y 2L REMARKS
County Parcel Identification No.(PIN),
5b.Latitude and Iongitude in degrees/minutes/seconds or decimal degrees: _.
(if wcll field,one latllong is sufficient) 22.Certification:
36 N ?or
6.Is(are)the well(s) ermanent or 07remporary Signature of Certified Well Contractor Dat
r By signing this form,I hereby certifp that the weII(s)was(Were)constructed in accordance
7.Is this a repair to an existing well: I Xes or _ No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repdu^,fill out known well construction informatio and explain the nature of the copy ofthis record has been provided to the Well owner.
repair under#21 remarks section or on the back ofthisform.
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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7-0s A) 24a.For All Wells: Submit this form within 30 days of completion of well
For mukfple wells list all depths ff&ffereut(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: �b (fL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. (m) 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 constriction method: try 1'Y�t / construction to the following:
(i.e.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: 24c.For Water SunDly&Injection Wells: In addition to sending the form to
��� the.address(es) above, also submit one copy of this form within 30 days of
4 —
13b.Disinfection type: •-- Amount: 6�?� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Emnronmenud Quality-Division of Water Resources. Revised 2-22 2016