GW1-2022-08517_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
-Cameron Bazin 14.WATER'ZONES'.. :.. ..:...,..
Fft.
TO [59
ESCRIPTION
Well Contractor Name fL
451 B-A n. ft
NC Well Contractor Certification Number I&OUTER:CASINC:' ormalti cased 5vells ORL'INER'da
Aqua Drill, Inc. FROM TO D R THIL7QYESS MATERIAL
R. � fL 1 . 6 in.
Company Name
_ f()O/� 16.IlVDiER CASING'UR Tf7BIlVG: bthermal closed-l6o
2.Well Construction Permit J-1 ( FROM TO DIAMETER r�ceavEss If
ERIAL
List all applicable well cons pern:its +e UIC,County,State,tlariance,etc) It. fL In.
3.Well Use(check well use): f tL in
[Agdcultrund
Supply Well: 17.SCREEN'-
Water
PP Y FROM TO DIAMETER " SLOTSIZE THICKNESS bATERIAL
DMunicipal/Public ft. it in.
ermal(Heating(Cooling Supply) Residential Water Supply(single) fL ft.trial/Commercial DResidential Water Supply(shared) 1S GROUT
tiOn FROM TO MATERIAL F.MPLACEMENTMETROD&AMOUNT
Non-Water Supply Well: 67
tL ft r
Monitoring DRecovery n• IL
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Ifa licable .
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACENEN'rMETHOD -
Aquifer Test [)Stormwater Drainage R• it.
Experimental Technology 'OSubsidence Control R
20.DRILLING LOG attach additional sheets if necess
Geothermal(Closed Loop) ®iTracer
_ FROM TO DESCRIPTION(color hardness.soilfroek a Ia size.etc.
RGcothermal(Heating/Cooling Return) Otthc,,r(explain under#21 Remazks) atfL
4.Date Well(s)Completed:_. 2-Vl'ell ID# ft• y
ft. ft.
5a.Well Location: _! yy
ft. ft.
Facility/ wrier Name Facility 1D4(if applicable) h• ft.
Z r,eL r it, fL ..
Physical Address,City,and Zip ( f
ft. unit—
�j 2L REMARKS
rlf, MUM00
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/iong is sufficient) 22.Certification:
�
��'� r —No• 6��o W
Lor
6.Is(are)the wells)4�� Permanent or OTemporary Sign re of Certified Well Contractor Da
By signing this form,I hereby certify that the wells)was(nee)constructed in accordance
7.Is this a repair to an existing well: QYes oro with ISA NCAC 01C.0100 or 15A NCAC 02C.0100 WeII Construction Standards and that a
1Jtlris is a repau;flit out Jmoxm well rnnslrnrctian injonmtfo d explain dre nature
of the caPP ojlhrs trcord has been provided to the well owner.
repair under#21 neniarks section or on the back of this form. 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 if necessary.
drilled: �/ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ft•)` 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells 1W all depths ifd fferent(example-3 r@r 200•and 2@ 1001 construction to the following.•
10.Static wager level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifitwer level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. pn•) 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: /[r1&%JQ4 construction to the following
(i.e.auger.rotary.cable,direct push,etc '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: 24e-For Water Sunnly&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: Amount: completion of well construction to the county health department of the county
where constmeted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22 2016