GW1-2022-06864_Well Construction - GW1_20220719

WELL CONSTRUCTION RECORD(GW I) For Internal Use Only: PrntForrnF
I.Well Contractor Information:
Cameron BaZlll '14;WATEkZONEs;
Well Contractor Name FROM TO DESCRIPTION -
4518-A S/ r`' %
NC Well Cant<actorCertifica6 ft. ft.onNumber
45.'OUTERCASING for+"muttiLes edwells,ORLINER'd:a licalile;.
Aqua Drill, Inc. FROM T DIA THICKNESS MATERIAL
Company Name ft. ftCe? i in.
&INNER':CASING:ORTUBING,''eotit ab`clasedaao
2.Well Construction Permit
I I FROM TO DIAMETER' THICKNESS MATERIAL
List all applicable well construction permtts(i.e:UIC Count),State,Variance,eta) ft. M in.
3.Well Use(check well use): ft: ft in
Water Supply Well: 17.SCREEN',,,.: _
FRONI TO DIAMETER I SLOT SIZE THICKNESS MATERIAL,
Agricultural OMunicipal/Public ft. % in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
ft It. in. ,
IndustriaUCommercial Residential Water Supply(shared) MfGROU
hri atiOII FROM- TO MATERIAL,. EMPLACEMENT METHOD&AafOUN1'
Non-Water Supply Well: tQ ft. 2 ft G ! S
Monitoring DRecovery ft &
Injection Well:
Aquifer Recharge oGroundwaterRemediation ft ft. i
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL"PACK if a lf6b1e
ty FROM TO I MATERIAL EMPLACEMENT METHOD'
Aquifer Test oStormwaterDrainage ft ft
Experimental logy
oSubsidence Control ft.. ft
Geothermal(Closed Loop) 1T�acer
20 DRILLING LOG attach additionafsheetsif-n"
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardnes,6o ck e, rain sia etr.
���� � ft- �v fL 51w�
4.Date Wells)Completed: Well ID# ft. �_Ds it. Ink
$a.Well Location: S ft ftri
y+7V/� ���' ft C 6 t s
Facility/Owner Name �— Facility lD#(if applicable) ft: ft.
223 �� s a� r r�t ,.��y � fL
fL
Physical Address,City,and Zip fL ft .ocix•==at,'vie
o//Y7 bl is 1 1,21:REMARKS," 11 r 7
county Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wellfield,one
/lat/long is sufficient) p 22.Certification:
6.Is(are)the wells)'_:Permanent or OTemporary Srgnatma otcettified Well Contractor Dale
By signing this form,I hereby certifp that they well(sJ was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or r No with ISA NCAC 02C.0700 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a'repair,fill out known well construction informati and explain the nature of the copy ojthis record has been provided to the well owner.
repair under#21 rernarkv section or on the back ofthisjorm.
23.Site diagram or additional well details:
S.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 attack additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total l well e wells depth below land surface:
For mu (ft) 242. For All Wells: Submit this form within 30 days of completion of well
multiple list all depths if (example-3Q200'and 2Q100� i•
construction to the following.
10.Static water level below top of casing:
Iftvater level is above casing;use"+'• � (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Centerl Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: i-y fzf ay above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) O constriction to the following: + '
FOR WATER SUPPLY YVELLS ONLY: Division of Water Resources,Underground Injection Control Program,
f 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Sr i 24c..For Water Sumily&Iniection Wells': In addition to sending the form to
the address(es) above, also submit one jcopy of this form within 30 days of
13b.Disinfection type: Amount: lCO2 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
Reused 2-72-2016