GW1-2022-08447_Well Construction - GW1_20220510

.:Run
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin
14:WATER'ZONES' _
FROM TO DESCRiPTION
Well Contractor Name fL /�s t40
4518-A ft, r♦ rL
NC Weil Contractor Certification Number 15:OUTER:CASING or multi cased wells OR L2NER d a lieable
Aqua Drill, Inc. FROM To D R TaILIavEss MATERIAL
AL
Company Name -16.INNER CASING'URrQBING 'eothermalclosed-loo
�� FROM TO DIAMETER THICKNESs MATERIAL
2.Well Construction Permit#: - in.
List all applicable well construction permits fi.e.U County.State.Mariano etc) ft'
3.Well Use(check well use): m
Water Supply Well: 17.SCREEN
P FROM TO DIAMETER SLOTSIZE THICKNESS hfATF.RIAL
Agricultural IOMunicipaL/Public ft. ft. in•
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R M fa
Industrial/Commercial Residential Water Supply(shared) 1S GROUT
I ri ation FROM TO MATERIAL EMPLACEMENTMECROD&AMOUNT
f
ater SuPP1Y Well: Q [t. ft ��itoring Recoveryion Well: R, iL
iferRecharge OGroundwaterRemediation19.SAND/GRAVII.PACK-d a Hcable .ifer Storage and Recovery '�r0SalinityBarrier FROM To MATERIAL EMPLACFMENTMslaoD
ifer Test [IStormwater Drainage R• ft.
Experimental Technology OSubsidence Control ft.
Geothermal(Closed Loop) [3Tmcer 20.DRILLING LOG a additional sheets if necem
Gcothcrmnl(HeatinJC-lin Return) Other(explain under#21 Remarks) FROM To DEscRrrnoN come aardness soiuuoek a ia:aq t+�
�
?D.� trt2
4.Date Weil(s)Completed: 7 `ell EM R' �9 s R fte,
R. iL
5a./Well Location: RE
L/aS4"t n /I�I�t�DxA�t tL ft.
Facility/Owner Name Facility lD4(if applicable) ft. R
lt` //10p6L' f,. L-ke sa^!0"*r— tr
Physical Address,City,and Zip ft.
I'G 21.REMARKS
County /C Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/iong is sufficient) 22.Certification:
3�: So�32 N ��.2r88� W
/., 2
6.Is(are)the well(s)ePermanent or [ITemporary Sign re oTreirtifiedWeil Contractor Date
By signing this form,1 hereby cerlty that the wells)spas(were)mnsmtcted in accordance
7.Is this a repair to an existing well: OYes or No with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Consticton Standards and that a
If this is a repair,fill out known well construction infommtl and explain tie nature of the copy of this retard has been provided to the well owner.
repair under 421 remarks section or on the back of thisform. 73.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
constriction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a.For All Wells: Submit this fowl within 30 days of completion of well
For nnultple wells list all depths ifdifferent lexample-3@200 and 2Qa 1005 construction to the following:
10.Static water level below top of casing: (N Division of Water Resources,Information Processing Unit,
ifiswer level is above casing.use"+/' ' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. t7 (in.) 24b.For Injection 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: ( �� construction to the following.
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,,�,Q��� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /`�' Method of test: � � 24c.For Water Suonlv.&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-
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Rcsourm, Revised 2-22-2016