GW1-2022-08593_Well Construction - GW1_20220516

Print Form.:. :;
WELL CONSTRUCTION RECORD(GW-1) For internal Use Only-
1.Well Contractor Information:
4
Cameron Bazin 14:wATERZONES'.
FROM TO DESCRIPTION
Well Contractor Name ft ft
4518-A
ft, ft
NC Well Contractor Certification Number 15:OUTER.CASING or muld-cased wells ORMNER11fabu
Aqua Drill, Inc. FROM T DIAMEPER TMCKNEss MATERIAL
ft. 8 ft ln.
Company Name /�� ���f� �f 16.INNER CASING"ORTUBING: othermalclus -60
2.Well Construction Permit#: 2- 20o Z ` FRom To DLAN ErER I TWCt?ss M&TERrnr.
Lis[all applicable well construction permits(;e.UIC,County.State,variance,etc)
ft. fL ln.
EL in.
3.Well Use(check well use): ft
i Well: 17.SCREEN':
Water Supply Y FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
:)Agricultural Agricultural lDMunicipallPublic ft. & in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft fa
Industrial/Commercial DResidential Water Supply(shared) E
FROM
GROUT ,
TO MAT/ERIAL FMPLAL' MENTMEfROD&AMOUNT
-!Irrigation
FROM
Non-Water Supply Well: ft 22-'ft Gft
Monitoring ORecovery M ft
injection Well: ft, ft.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL TACK Sa liable .
Aquifer Storage and RecoveryOSalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
Aquifer Test [)Stormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
RGeothermal
Geothermal(Closed Loop) Tacer 20.-DRII LINGLOG attach additional sheets ifneemaFROM TO DESCRIPTION(color hardneasoIVroek % ra ere.(Heating/Cooling Return) Othcr(explain under#21 Remarks) ft O fi,
4.Date Wells)Completed:_r Well ID# ft. gs ft. OYV
ft. ft.
5a.Well Location: �1
Mtn bol/trlq I.ft. ft
Facility/Owner Name Facility ID#(if applicable) ft' ft' t
lvl—
ft. ft
ft tc
Physical Address,City,and zip
S
2L REMARKS�►rry 2 7rinrMn County Parcel Identification No.(PIN) DWorROc3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fields,one lat/long is sufficient) r� 22.Certification:
U. �??!? N
6.Is(are)the well(s),IPermanent or OTemporary Signature ofCertiSed Well Contractor Dam
( By signing this form;I hereby curb that the well(s)was(st e)coarmwed in accordance
1.Is this a repair to an existing well: OYcs or No with ISA NCAC 02C.0100 or 15A NCAC 02C.OZ00 Well Constriction Standards and that a
If ilds is a repair,fell out known well construction information and explain the nature of the copy afrhfs r-ecord has been provided to the well owner.
repair under#21 remarks section ar•on the back of t►tis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a.For All Wells: Submit this forma within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2000''a g
nd 2@100) construction to the followin
( .
10,Static water level below top of casing: 7 O (ft-) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing,use^+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (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: /o 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: S L(� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3'D Method of test: ✓r,R• 24c.For Water Suonlv-&Injection Wells: In addition to sending the form to
_I the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: !(pOZ completion of well construction to the county health department of the county
where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources