GW1-2022-06859_Well Construction - GW1_20220720

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATERZ01'M
FROM I TO DESCMUON I
Well.ContractorName us z
4518-A
fr. ft. I
NC Well Contractor Certification Number is.OUTERCASING for multi cased wells OR LINER fff a livable
Aqua Drill,Inc. FROMTO DfAMl1ERIF THICKNESS MATERIAL
It
S ft. in.
CompanyName O'q ^
16.IlVNERCASINGOItTUBING' eothermalclosed-loo
pv(
2.Well Construction Permit#: FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits VA U1C,County;SW4 Variance eta) ft ft. �
3.Well Use(checkwell use): ft' f in
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER I SLOT SIZE I TntCKNPSS I MATERIAL
AgriculturalL„p�Municipal/Public fL ft. in-
Geothemtal(Heating/Cooling Supply) Mesidential Water Supply(single) fL fL in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT-
IF hri ti0n FROM TO MATERIAL
EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Welh o fL ff
Monitoring ±.Recovery ft. ft
Injection Well:
fL
_,Aquifer Recharge E)GioundwaterRemediation
19.- Aquifer Storage and Recovery OSalinity Barrier FROM TO �A MATERM F"LACEMEN METHOD
Aquifer Test 1'.stormwater Drainage fL ft.
Experimental Technology i]Subsidence Control ft. ft.
Geothermal(Closed Loop) [ITracer 20.DRHJMG LOG attach additional elieetsif neces
FROM I TO 'DESCRIPTION color,hardness,solUzoek type,prain size,etc)'.
Geothermal(Heating(Cooling Return) -Other( lainunder#21 Remarlm) fL iS fL 1,
4.Date Weli(s)Completed: AITWI Well ID# ft, it j
a
ff. ft 5a Well Location: �
�htt�y � �. ft. �e: r
�.i� �`'�.� .; -w
Facility/OwnerName -Facility ID#(if applicable)
fL ff.
PhysicalAddress,City,andZip ft. fL
Y / 2LREMARKS nt.,iy3 ire:. !�t(a
1f:rLti Clnnai iL';7 Yli)v1 ck E by 9�I\T I
County Parccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one tat/long is sufficient) 27-Certification:
i
6.Is are the well(s)
.ermanent or Tem ora Signature of Certified Well Contractor
By signing,ihis form,I hereby certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair well: []Yes ®r — No with 15A NCACO2C.0100 or15A NCAC 02C.0200 Well ConstructionStandardsand thataifthisisarepatr,filloutkhzotvnwellcmtstr=tioninformatexplain the nalure ofthe copy ofthis record has beenprovidedio the Hell owner.
repair under it21 remarks section or on the back of thisform.
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 constmction details.You may also attach additional pages ifnecessary.
dui SUBMITTAL INSTRUCTIONS
c {
9.Total well depth below land surfacer J ( ) 24a,For All Wells: Submit this form within 30 days of completion of well
For mu&ple wells list all depths ifdifferent(example-3@200 and2Q1009 construction to the following.
10.Static water level below top of casing: �� (ft:) Division of Water Resources,Information Processing Unit,
ftvater level is above caring,use"+" 1617 Mail Service Center,Ralelgh,NC 27699-1617
1L Borehole diameter. (in.) 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: �A b clk construction to the following:
(Le.ouge,roluy,cable,directpusb,etc.) 7
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: --LL�-- 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) ten. Method of test- N�rP/� 24c.For Water Supply&Inection 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: a2. 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
t%s -