GW1-2022-07934_Well Construction - GW1_20220823

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WELL.CONSTRUCTION RECORD(G W 1) For Intemal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
451 S--A it tt yo
NC Well Contractor Certification Number
15.OUTER CASING for nioiti-cased wells OR LIlVER a livable
Aqua Drill,Inc. FROM To DIAMETER T�ctnvESS1 MATERIAL
ft Sg in.
CotttpatryName
16.INNER CASING OR TUBING(geothermal closed-loo
2.Well Construction Permit f EIS&GROUT
TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l e.OIC,Count};Stag Variance etc) ft m'
3.Well Use(check well use): % In.
Water Supply Well: EN
TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural �MunicipaUPublic R fn.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft in.
Industrial/Commercial Residential Water Supply(shared)
.inI[r'1 tion TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O � ft s
_ Monitoring DRecovery fL %
Injection Well:
Aquifer Recharge orroundwater Remediation t1. ft.
19.SANDIGRAVEL PACK f a livable
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
quiferTest OStormwater Drainage fL III
Experimental Technology lOSubsidence Control ft. ft
Geothmnal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets If nee
FROM TO DESCRIPTION color,hmdn solUroek in Am etc.
_Geothermal eatiDg/Cootinjg�Retiprm Other(explain under#21 Remarks) Q & •to & 5�1
4.Date Weli(s)Camp]eted:V C Z Well D30 0 ft �2� fL
Sa.Well Location: ft ft
Facili��-ty/Owmx mNae Facility W#(ifapplicable) ft ft
T p.l�r j
` —Ar1Xe4- �/� / lCl/g tt it r�W � Unit
Physical Address,City,and Zip ft. fL 261013OG
4-O�C 21.REMARKS
County J Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
3 G.32 S f t lv >�b. 3?�i g? w
2
6.is(are)the well(s�Permaneat or (Temporary S9rgaature of Certified well Contractor Date
By signing Uric form,I hereby ceWfy that the rvell(s)um(were)constructed in accordance
7.Is this a repair to an existing well I)Yes or4.d
No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,full out known null conshuction informs'arplain the nature of the copy ofthis record has beau provided to the well owner.
repair under 021 remarks section or on the back of thisfarm. 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 aonstiuction details. You may also attach additional pages if necessary.
drilled' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For mrrltr'ple welts list all depths dfffereuu(ucrorrtple-3Qa[00'sad IQa 7001 construction to the following:
10.Static water level below top of casing: 7 (ft) Division of Water Resources,Information Processing Unit,
Ywater level is above casing,ruse"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �m above,also submit one copy of this form within 30 days of completion of well
(i.e.anger,rotary,cable,direct push,etc.) IF
Construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield m QO C t l
(gp ) / Method of test: S/ � 24e.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: !�Q Z�— completion of well construction to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Reused 2-22-2016