GW1-2022-07536_Well Construction - GW1_20220815

i
WELL CONSTRUCTION RECORD(GW I) _ Print Form
For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin
14.WATER ZONES i
Well Contractor Name FROM TO DES
4518-A f ft• ft /0
NC Wcll Contmctor:ertification Number fL
Aqua Drill, Inc. 15.OUTERCMING formaltitasedwells OR LINER ifa iltable
FROM TO DIAMIETER 7titCICNESS MATERIAL
Company Name O ft. d7 fie in.
I&INNER CASING OR TIIBING eothermal closed-loo 2.Well Construction Permit A. Z02I �37 d FROM To DIAMETER THIC;4tr-2 MATERIAL
List all applicable ee11 cotutrucdon permits(i.e.U1C,Cai State,Variance,etc.) ft. R in.
3.Well Use(check well use): ft, iL in
Water Supply Well: 17.SCREEN
AgftCalhll8l FROM TO DIAMETER I SLOTSIZE MTF
icipaYPublic ftGeothermal(Ileating(Cooling Supply) idential Water Supply(single)
Industrial/Commercial ft. inResidential Water Supply(shared) 15.GROUT
Iai lionMATERIAL ER7PLA
Non-Water Supply We11: O fit 22 ft
Monitoring Recovery ft. ft
Injection Well:
Aquifer Recharge oGroundwater Remediation ft.
Aquifer Storage and Recovery OSalinitY Battier 19.SAND/GRAVEL PACK if livable
FROM TO MATERIAL "'ENT METHOD
quiferTest oStormwater Drainage ft ft
Experimental Technology [3Subsidence Control R ft
Geothermal(Closed Loop) Tracce 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Fleating/Cooling Retum) Other ex lain under#21 Remarks FROM To nEseRlrttoN coral'hardam scivrock n s;re,etc.)
� ft. fit fc� 11
4.Date Well(s)Completed: 2- - Well ED# Q fit �' •'T4
5a.Well Location:
yot+Y� ��ar�i ft. fit
Facthty/Owner ame /1 FacilityIp#(ifapplicable) ft fit
1(7 P"�'�f 1�/ � {�I tI� fit ft
Physical Address,Cny,and Zip ft iL AUG v
J� �Q( {.j y 21.REMARKS
County
Parcel Identification No.(PIN) ypt
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient)
`�ay 22.Certification:
T W Z2
6.Is(are)the welfeII(stiPermanent or oTemporary S,gaautte of t.ernfied WeII Conitactor Date 7 42
7.Is this a repair to an existingwell: �yeg or By•dgning this forth,1 hereby certify that the well(a)was(xere)constructed in accordance
�ZeVlain
o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out blown well construction information Use nature 4f the copy Of this record has been provided to tyre well owner.
repair under#21 remarks section or on the back of this 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional es ifnec drilled. P� necessary.
ZGS
9.Total wen depth below land surface: SUBMITTAL INSTRUCTIONS(�)
For mula'ple wells list all deada fd1i erem(eample-3@200'and2@100) 242-For All Wells: Submit this form within 30 days of completion of well
sO construction to the following.
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing. '
1L Borehole diameter:
1617 Mail Service Center,Raleigh,NC 27699-1617
(�_)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:ere. {Q{�'i{{7/ above,also submit one copy of this form within 30 days of completion of well
(i_e.auger,rotas;cable,direct push, ) construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)10 Method of test: 40 24c.For Water Suably&Infection Wells: In addition to sending the form to
13b.Disinfection type: Amount the address(es) above, also submit one copy of this form within 30 days of
completion of well construction toithe county health department of the county
where constructed.
Form GW-I North Carolit Department of Environmental Quality p Q hty-Division of Water Resources Revised 2-22-2016