GW1-2022-06862_Well Construction - GW1_20220719

i
I - _Print Forrn
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
WellContractarName FROM TO I DFSCRIPTION
4518-A ft ft
ft. ft I
NC Well Contractor Certification Number 15.OUTER CASING{for molti�esed wells)ORLINER rf a livable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft 'in.
CompanyName
^ 16.INNER CASING OR TUBING eothermal closed loo
2.Well Construction Permit#: `/ FROM TO DIAMETER TfflcmmS MATERIAL
List all applicable ivell construction permits(i.e.UIC,Cora*1.Stata Variancrl etc) & ft ^in-
3.Well Use(check well use). ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THTCKNESS I MATERIAL
Agricultural Municipal/Public ft ft. in.
Geothermal(Reating/Co.h.g Supply) R3Residft.IWtcr Supply(single) ft ft in-
hrdustrial(Commemial Residential Water Supply(shared) 18.GROUT
--blorigatio, FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nos-Water Supply Well: ® ft 2,3 ft
Monitoring 0Recavery ft. ft. i
Injection Well: & ft
Aquifer Recharge oGrOUndwaterRemediation
19.SAND/GRAVEL PACK livable '
_:.Aquifer Storage and Recovery 0salinity Barrier FROM I TO I MATERIAL' I EMPLACEMM r METHOD
: . Aquifer Test OStormwater Drainage ft. I %
:. Experimental Technology OSubsidence Control ft. I ft I '
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if nee
Geotheanal FROM TO DESCRIPTION color,hardrim,soNrock e a stir,eta.
(Heating/CoolinggfReturn)) Other(explainunder#21Retn .)) ti
4.Date Well(s)Completed:` !/ Well ID# ft. tt
Sa.Well Location: ft. ft 1 i>p
4-A-0l"Aft ,rut,F f3' ft. %
Facility/OwnerNama Facility ID#(ifapplicable) ft. ft 02?
yAc ,ram. �i r��,1 ft. ft
Physical C Us�,va...iNTltisl7
ys , ul;and Zip '� ft ft
1�kr^ ►rt t Wti rl ,F13 111
21.RF.MARKC
I
County Parcel IdentificationNo.(PIS
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
(if wcll field,one lat/long is sufficient) g q 22.Certification:
�G, -f2SS� IvQ S/T8 f'3 W
6.Is(are)the well(s) Permanent or Temporary SiguatureofCcrtifled Well Contractor 1
By signing this fonn,I hereby cer7h•that the well(s)uns(were)constructed in accordance
7.Is this a repair to an existing well: Dyes orZ[No with ISA NCAC 02C.0100 or 15A MCA 02C.02001fell Construction Standards and&at a
Ifiltis is a repair,fill out I--well construction irrformah0i and explain the nature of the Copy ofthis record has been provided to the),tell ownen
repair under#21 remarks section or on Are back of tlrisform. t
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe 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.
drilled:
�J SUBMITTAL INSTRUCTIONS !
9.Total well depth below land surface: �` 24a.For Al[Webs: Subarit this form withi. in 30 days of completion of-,veil
fk
For multiple wells list all depths ifdfferent(=ample-3 rQr 200'and 2@100� ) 24a.cons or A to the following j
10.Static water level below top of casing
If water lever is above casing,rose (ft) Division of Water Resources,Information Processing Unit,
+^ ,
1617 Mail Service Center,Aaleigh,NC 27699-1617
11.Borehole diameter: (inn) 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: 4 re� construction to the following:
(Le.anger,rotary,cable,&-tpush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of best 24c.For Water SunDly&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.
Fomt GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016