GW1-2022-08819_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD(GW--1) For Intemal Use Only.
1.Well Contractor information:
Cameron Bazin 14.WATERZONES
FROM TO DESCRIPTION
f,Well Contractor Name fL
4518-A `t ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if liable
Aqua Drill,Inc. rROM To DIAMEZTR T�fTCNESS MATERIAL
ft. 6 ft- in.
CompmyName
//� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: O f 1-) s/ FROM To D1Ar0vETER Te1C[avEss MATERIAL
List all applicable well comb uction perauts(r.e.WC Comity Stag Pariaact eta) � ft in.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
FRON TO TIDILAMETER SLOTSiZE "HCKNESS MATERIAL
Agricultural DMunicipaUPublic fti Geothermal(Heating(C-1mg Supply) Wesidential Water Supply(single) % in
IndustriaUCommercial 0Residemiai Water Supply(shared) IS.GROUT
i Irrigation FROM TO MATERIAL EMPLACEMENT METHOD d&AMOUNT
Non-Water Supply Well: 22.
>Z j
Monitoring [_Recovery ft. &
Injection Well:
Aquifer Recharge DGroundwaterRemediation %
Aquifer Storage and Recovery DSalioity Barrier FRoaAND/GRAVEL PACK MSappli ATERIAL HriPLACEMENT M6TltOD
erlrest DStomiwaterDrainage ft it
Experimental Technology OSubsidence Control & &
Geothermal(Closed Loop) OTraoet 20.DRiLLING LOG attach additional sheets if ne
Geothermal(Heatin Cooling Retum) Other( lain under#21 Remarks FROM TD DESCRIPTION mmr,i,araa eorveuck stu ere
tt. S & 0L
4.Date Wetl(s)Completed:_49J// Well ID# R ft r < , F
Sa.Well Location:
r & ft
:ramp ft. SAP Q6 G•2022
Facility/OwnerName T Facility ID#(ifapplieable) fL %
O li� ft rt
vva- 0G
Physical Address,City,and Tsp ft' r
Y, A LhA 21.REMARKS
CO-7 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
3G . t yl em N 48,9--60 w �` � B Y ZZ
6.Is(are)the well(s) Permanent or (OTemporary Signature ofCertified well Contractor Da
By signing this jamb 1 hereby ratify that the weB(s)xns(ivere)constructed in accordance
7.Is this a repair 4 an esiSting well: I�Yes or o with 15A NCAC 02C.0100 or ISA NCriC 02C.0200 Well Construction Standards and that a
Ijthis it a repair,fin(out Arson well construction fajoratatio and explain the nature of the copy of this record has been provided to the x ell mynas.
repair under#21 remark sectlatr or on the bark oftlusfo 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 OW-1 is needed. Indicate TOTAL NUMBEEt of wells construction details.You may also attach additional pages ifneoessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total wen depth below land surface: *3 6 0Q 24a.For All Wells: Submit this form within 30 days of completion of well
For mulWe wells list all depths tfdrffercnt(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use+" 1617 Man Service Center,Raleigh,NC 276994617
11.Borehole diameter: (io-) 24b.For Infection Wens: In addition to sending the form to the address in 24a
f� above;also submit one copy of this form within 30 days of completion of well
12.Well construction method: ` 1
C1/ construction to the following:
(i.e.anger,rotary,cable.direct push,ac.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service'Center,Raleigh,NC 27699-1636
C
13a.Yield(gpm)1_ Method of test:✓d1t � 24c.For Water Supply&Infection Wells: In addition to sending the foffi to
the addresses) 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 r:onstructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016