GW1-2022-07556_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only.
I.Well Contractor Information:
Cameron Bazin 14.WATER TONES
Well Contractor Name FRONT TO DFSCRIPT(UN
4518-A ft & ,�j14A
ft ft.
NC Well Contractor Certification Number
15.OUTER CASING for mniti�ased we11s OR LINER if a livable
` Aqua Drill, Inc. FROM I To I 111AMErER TMCKNESS MATERIAL
CompaayName
@. O fk 6 in.
373 t 16.INNER CASING OR TUBING eothermal closed-lootil
2.Well Construction Permit#. FROM TO DIAMETER I THICK ESs MATERIAL
List all applicable Kell construction pernrtts T e.UIC,Cormtlt State,Parlance,etc.) ft. ft IIn.
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO OTAMETER SLOTSIZE THICKNESS MATERIAL
Mimicipal/Public ft in
Geothermal(Heating/Cooling Supply Residential Water Supply(single)
tt ft in
Industrial/Commercial [3Residentiai Water Supply(shared)
1&GROUT
IIri ti0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOtIhT
Non-Water Supply Well: O ft fL �t .
Monitoring Recovery ft.
Injection Well:
Aquifer Recharge R•
Groundwater Remediation
Aquifer Storage and Recovery19.SAND/GRAVEL PACK rf a livable
oSfllimiw Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �Stormwatet Drainage tt• ft
Experimental Technology Subsidence Control It. fz
Geothermal(Closed Loop) DTracer 20,DRil,LING LOG attach additional sheets if aeces
Geothermal(Ileating/Cooting Return) Other ex lam under#21 Remarks) I To DESCRITION color,aardnes sorurack rda size.etc©
R ft01
4.Date Well(s)Completed:_ �/�2�Well ID# ft. ff.
5a.Well Location: It. fL
s .s
t
A
ty/Owner N t �f Facility ID#(if applicable) ft ft
I�� C�rr�t�Gn�- //� livDl�i�lC(tWG,�L ft ft.
Iftlarrr, ac�;.
T►—�_ 4.
Physical Address,City,and Zip
REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
W
6.Is(are)the well _- Permanent or I�Temporary Signature ofCemfied Well Contractor Dare 19z—
By signing this form,I hereby certify that ithe wW(s)was(were)constructed in accordance
7.Is this a repair to an existing well: l�Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 well Construction Standards and that a
If this ISO repair,fill out known well construction it forma' and. lain the nature of the COPY ofthis record has been provided to the xell owner.
repair under#21 remarks section or on the back gjthis form.
23.Site diagram or additional well details:
9.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:
t' SUEMLTTAL INSTRUCITONS
9.Total well depth below land surface:_ 7 S (fL) 24a,For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 1Q100)
construction to the following.
10.Static water level below top of casing: 7 ljrwter level is above casing,use (fL) Division of Water Resources,Information Processing Unit,
`4"
1617 Mail Service Center,Raleigh,NC 2 7699-1 61 7
11.Borehole diameter: {in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ✓�7fG/t6 above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rota • - construction to the following-
FOR rotary,cable,direct push,etc.) wing:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
,,r^1 ( 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) LV Method of test: 10 r 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 completion of well construction to the county health department of the cotmty
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22_2016