GW1-2022-07743_Well Construction - GW1_20220815

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES f
Well Contractor Name FROM TO DESCRIPTION
4518-A G �'
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING for ma►tieased wells OR L1NER>f licable
Aqua Drill, Inc. FROM TO D TffiCKNESSI MATERIAL
ft. ft. in.
CompanyName
Al
16.INNER-CASINGORTIJBING(geothermal closed-loop)
2.Well Construction Permit#: 0 AI •7/ FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits Ci.e.LAC County,State,variance,etc) ft. % hL
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FROM TO DTAMLrrER SLOT SIZE THLCKNESS MATERTAL
,:Agricultural `_ Municipal(Public ft ft. hL
Geothermal(Heating/Cooling Supply) Mesadential.Water Supply(single) ft ft. to,
:]Industrial/Commercial Residential Water Supply(shared)
IS.GROUT
Inigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 2L &
Monitoring ORecovery ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation ft ft.
19.SAND/GRAVEI,PACK rifapplicable)
Aquifer Storage and Recovery DSalinityBarricr FROM To MATERIAL EMPLACEMENT METHOD
quifer Test OStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if neeessmyl
Geothermal(Heating/Cooling Retum) — Other(explain under#21_Remarks) FROM TO DESCRTMON color,hardness,suIDrock rain AT,era
6 ft 'O ft Q60 L., i , f'° —d" "
4.Date Well(s)Completed: WeU M# 40 it. !0$ ft. %"-. -
5a.Well Location: ft' ft. 1J r 1 v
Add ft. ft
S f�J.aielatt. Ilni
Facili Ty/Owner Name Facil Y 00 t PPlicable)ifa ft ft Ifl min"' 0v l �
1 t9+!
744q 6" fu,! f f
Physical Address';.City,and Zip .01
_ WiKiA 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
3 A.0,99 20 IN W 2Z
6.Is(are)the well(s) Permanent or L�I_ Temporary Signature of Certified well Contractor
By signing this form.1 hereby cerg6,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or"o with 15A NCAC 02C.0100 or ISA NCi1C 02C.0200 Nell Construction Standards and that a
Ifthis is a repair,fill out blown well construction iuformat/ and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 02l remark section or on the back of thisform 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 ifnecessary.
drilled. SUBA=AL INSTRUCTIONS
9.Total well depth below land surface: .5095 00 24a.For All Wells: Submit this form within 30 days of completion of well
For rmdnple wells list all depths if different(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: n (ft.) Division of Water Resources,Information Processing Unit,
jwater level is above casing,use"+^ 1617 Mall Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: (m.) 24b.For Iniecdon Wells: In addition to 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: C04T
(i.e.auger.rotary,cable,dit push,etc,) construction to the following:
cct
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service&nter,Raleigh,NC 276994636
13a Yield(gpm) Method of test: 24c For Water Sup
ply&Injection 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: Aqy Amount: lraa?i completion of well construction Ito the county health department of the county
where constructed.
Form GW-1 North Carolina Departmem of Environmental Quality-Division of Water Resources Revised 2-22-2016