GW1-2022-08410_Well Construction - GW1_20220519

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
L Well Contractor Information:
Cameron Bazin 14."WATERZONES'.
Well ContractorName FROM TO I DESCRIP N
4518-A 146p ft
a. ft
NC Wc1l ContraderCettiScationNumber
15:OUfER.CASING' ocmtrlti-rrsed��vclls ORI;INER rta ]lcable •'.:'•:'- '
Aqua Drill,Inc. FROM To D THICLQ�SS MATERIAL
ft. 60
ComparryName
-16.INNER CASING OR TOBING(geothermal closed-loop)
2.Well Construction Permit#: FROM To I DIAMETERI THICKNESS I MATERIAL
List all applicable ivdl construction pernd (Le.ls WC,Comm;State.Irarian'm e1c.) n• IL in.
3.Well Use(check well use): ft• ft in.
Water Supply Well: 17.SCREEN". .:
FROhI TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 01duaicipal/Public H. it in.
GeotheMol(Heating/CaoUng Supply) esldential Water Supply(single) R ft
lndustrial/Commeraial l EPResidential Water Supply(shared) 1&GROUT
Irrl ation FROM TO MATERIAL EMPLACFMENTMETROD&AMOUNT
Non-Water Supply Well: O R. ft.
Monitoring DRecovery ft. IL
Injection Well:
ft ft
AquiferRecbarge DGroundwat-Remediation
19.SA'ND/GRAVMPACKrifaDnlicableI.
Aquifer Storage and Recovery 0SalinityBarrier FROM To MATERIAL EMPLACEnIENTMEraOD
..Aquifer Test 08totrawaterDrainage R• it
_Experimental Technology OSubsidence Control ft. ft
• Geothermal(Closed Loop) ©1Tmcer 20.DRMT;1NGLOG attach additional sheets if necessary)
ITtOM TO DESCRIPTION color,bnrdnaw,xoillmck e,ernla sae,ern
Geothermal(IicatinJCoolingRctnm) ;' Othcr(explainunder#21Remarks) ft. ft
4.Date Well(s)Completed:�� 1;`ell IDm ft. ft
Sa.Well Location: R it
Facility/�OtivnerName FaciliiyIDR/(i/fappli/cable) ft.
7�i-'-7aG��i��� ✓•i �itfa`I[iC.//u'�I'I/�' ft. ft MAY7 _
Physical Address,City;acid Zip r ft ft -
r( 2L REMARKS
County Parcel IdentiffcationNo.(PIN) --1 '
IIV r'11�11`_/'J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwell field,one laVlong is sufficient) ryry 2L Certdieation:
��,,,, • !, •
6.Is(are)the wells)ll'ermanent or Temporary Sfgaarure ofCediBed Well Contractor Da e
(�T" By signing this form,I hereby certify that the ivell(s)was(irem)constructed in accordance
7.Is this a repair to an existing iveU: Dyes or NO Ivith ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Weil Comirucdon Standards and that a
Ifthis is a repair,jill oittkwuA it-ell construction information and explain die nature of the copy afih&tucordluu beenprovL&d to tha well o mer
repair under t-.`21 t asnarks section ar an file back-offbtsfamt
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 TOTALNUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled: SUBiVIITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 65 (ft) 24a.For All Wells: Submit this form.within 30 days of completion of well
For multiple wefts Gst all deptlu ifdifjerent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:- (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use-+•' 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter.A/+_(in) 241L For Iniection Wells: In addition to sending the form to the address in 24a
12 Well construction method: 1Q�GLr above,also submit one copy of this form within 30 days of completion of well
(fie.auger,rotary,cable,drtectpush,eta) construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test LtG 7_ 24a For Water Sunnly&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 county
where constructed.
Forth GW-1 North Carolina Deparhnent ofEnvironmcutal Quality-Division of Water Resources Revised 2 22-2016
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