GW1-2022-07290_Well Construction - GW1_20220805

Print Form:
WELL CONSTRUCTION RECORD(GW-1) r
internal Use Only: i
i
1.Well Contractor information:
Cameron Bazin la-WATz M
FROafER TOI DESCRIPTION!
Well Contractor Name 2y s IL
451 B-A fr. ft.
'NCWell Contractor CenificationNumber 15.OUTER CASING for multi-casedtvelis OR LINER da licable
Aqua Drill,Inc. FRO � TO � DIAMErER'lnl THICKNESS MATERIAL
1pf
I to
Compaw"Tame � 16.INNER'CASING'ORTUBING eothermalclosed:lao
2.Well Construction Permit#: J.7(D FROM To D MATERIAL
List all applicable xstl construction permits(i.e.UIC,CounO,.State,Variant&etc) M ft'
ft. ft 'im
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DTAMMR I SLOT SIZE THICKNESS MATERTAL
:jAgricultural ElMunicipaVPublic % ft. in.
Geothermal(Heating(Cooling Supply) RResidential Water Supply(single) ft. ft. In.
ludustrial/Cornmercial bResidential Water Supply(shared) 18.GROUT
.--h-rigatiou FRODI TO 11lAnItrAL' EMPLACEMENT METHOD&AMOUN-T
Non-Water Supply Well: 0 ft. 2,%
Monitoring ORecovery ft ft.
Injection Well: ft. ft
Aquifer Recharge OGroundwaterRemediation 19.SANDIGRAVEL PACK if- livable
._ Aquifer Storage and Recovery oSaliniry Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test OStomawaterDrainage ft ft
Experimental Technology IOSubsidence Control %
Geothennal.(Closed Loop) OITracer 20.DRILLING LOG attach additional Aeets'if necess
FROM TO DESCRIPTION color,bnrdness,solUrock in size,etc)
Geothermal(Aeating/Cooling Return) Mother(e lain under#21 Remark) % /,� ft.
4.Date Well(s)Completed: ?i Well ID# ft 2SS ft
ft ft h
Sa.Well Location:
1�cic,.� �
AU(k &
Facility/OwnerName Facility ID#(irapplicable) ft ft I, t a �9
NG OAAbwrv. It
Physical Address,City,and Zip ft. { ,
e2-i0f_ 2LREMARKS Ift v, •• f1
{�fG i
County Parcel Identification No.(PIN) r �
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latnong is sufficient) 22.Certification:
6.Is(are)the wells)OPermanent or IOTemporary Sigaa of Certified Well Contractor Dnte
By signing this form,I hereby certify that the well(s)ans(were)constructed in accordance
7.Is this a repair to an existing well: LYes or. ._ No with 15A NCAC 02C.0100 or 15A NCAC 02C 0200 R'ell Construction Standards and that a
If this is a Mpa1r,fill out kaorm Well constriction informs.n and explain the nature ofthe copy ofthis record has been provided to the»ell owner.
repair under#21 remarks section or on the back ofthis form. 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 construction details.You may also atta&additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2�� (H•) 24a.For All Wells: Submit this form within 30 days of completion of well
For rmdnple wells list all depths ifdifferent(example-3Q200'and2Qa 100) construction to the following:
I '
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
ff water level is above casing.rise"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: (m.) 24b.For Iniection Wells: In addition to i 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: ('e ttY construction to the following:
(ix-auger,rotary,cable,directpush,etc) f
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY
[W'ELLS ONLY: 1636 Matt Service Center,(Raleigh,NC 276994636
`.
13a.Yield(gpm) S Method of best. �7-� 24c.For Water Supply&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: W7� 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 WaterResources Revised 2-22 2016