GW1-2022-07293_Well Construction - GW1_20220805

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WELL CONSMUCTION RECORD(GW=1) For Internal Use Only: -- - _--
1.Well Contractor Information: i
i
Cameron Bazin
'14:,WATMZONES:.:•r l.;
Well Contractor Name FROM TO DESCRIM'ION
4518-A "S ft• ft p
ft. ft.
NC Well Contractor Certification Number
,15:OUPER:CASING(formulh casedwells:ORLfNER`tf,a licable_
Aqua Drill, Inc. FROM To DL TERt THICKNESS MATERIAL
CompanyName ft. O ft- im
`/Cps 16:-INNER CASING ORKZ1 BING'(eothermal closed loo _
2-Well Construction Permit#: /,(�J T FROM TO DIAMETER THICKNESS MATERIAL
List all applicable-Mil construction permits t±-e.UIC,Count3;State,Yariaace,etc.) ft, ft in.
3.Well Use(check well use): ft fL in.
rn
pply Well: ::11 SCREEN ttrral � Munici aVPublic FROAf TO DIAMETER• SLOT SIZE THICKNESSMATERIAL
P ft in.rmal(Heating/C-Img Supply) idential Water Supply(single)
al/Commercial '-Residential Water Supply(shared)
1S:GRORFROM TO MATERIAL EMPLACEMENT Mer Supply Well: ® ft ftring (-Recovery ft. ft.
Injection—Wen-
Aquifer
Rec a ft iL
oGroundwaterRemediation
19 SAND/GRAVEG)'ACK if a`Gcahle Aquifer Storage and Recovery n8alinity Barrier FROM To ntnTERrAI =ii
-
,
'-_..Aquifer Test �IStormwater Drainage ft. ft. I
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer
20:DRILL'ING LOG:attach eddiAouafsheets:i
Geothermal(Heating(Cooling Return) "Other 31ain under#21 Remarks) OaI To DESCRIPTION color hardness,soilfrocktype,grAu size.eta
14'm
4:Date Well(s)Completed: , Well ID# 7 0 ft.Sa.Well Location: ft.A MFacifitylOwnerName FacilityID#(ifapplicable) ft. lm.. y 9
r°'/Or j n, ft. ft. �.
Physical Address,City,and Zip ft. ft.
IY s21 REMARKS:
County Parcel Identification No. OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one latllong is sufficient) 22.Certification:
�. ,.,,/ N coo - evem w �: ? Z
6.Is(are)the well(s)Q/pYermanent or Signature of Certified Well Contractor Dal
� By signing this form,I hereby certify that the well(s)was(were).constructed in accordance
7.Is this a repair to an existing well: OYes or No with 15A NCAC 02C.0100 or 154 NCAC 02C.o20o Well Construction Standards and that a
If this is a repair,fill out known well construction informal' and explain the nature ofthe copy ofthis record has been provided to the'xell awner.
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 attach additional pages if necessary.
drilled: f
�8S SUB14lrTTAL INSTRUCTIONS
9.Total well depth below land surface: (R•) 24a.For All Wells: Submit this form within 30 days of completion of For multiple wells list all depths ifdifferent(example-3@200'and 2@100) well
construction to the following: '
10.Static water level below top of casing: - -f0 Ijrvater level is above casing,use (ft) Division of Water Resourcels,Information Processing Unit,
"+' 1617 Mail Service Center,lRaleigh,NC 27699-1617
11.Borehole diameter: �y (-in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: a Iy Ce above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,+Raleigh,NC 276994636
r �•
13a.Yield(gum) Method of test: / r 24c.For Water Suoniv&Injection Wells: In addition to sending the form to
136.Disinfection ejtr1f the address(es) above, also submit one!copy of this form within 30 days of
tYP • Amount 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 2-22-20 16