GW1-2022-08821_Well Construction - GW1_20220909

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WELL CONSTRUCTION RECORD((;W-1) For Internal Use Only.
L Well.Contractor InfOrMatiO-
Cameron Bazin 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name YoS rr.
4518-A
NC Well Contractor CettificationNumber 15.OUTER CASING for malti-ccased wells OR LIIMR if a liable
Aqua Drill,Inc. Mom ft. Ri DUMEtER tn. T�CIQYESS MATERIAL
© O
Compaayblame (' 16.INNER CASING OR TUBING(eothermai dosedd00
2.Well Construction Permit#: I✓�/�I�� FROM I TO DIAMETER THICitNESS MATERIAL
List all appilcable well construction permits f e.UIG,Cormtlt State.VarlanCe eta) ft ft'
in.
3.Well Use(checkwell use): ft. ft.
Water Supply 17.SCREEN
PP Y Well: FROM TO DIAMETER SLOT SIZE TRICf4VP3S MATERIAL
cultural MunicipaltPublic ft. fl: in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft, to
Industrial/Commereial Altesidential.Water Supply(sh—A) 1&GROUT
—lirrigatiou FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply well: ft
At i
Monitoring DRecovery ft.
Injection Well: R ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK a licable
quifei Storage and Recovery Salinity Banlcr FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStomiwater Drainage h
t(le,G
crimental Technology Subsidence Control ft
thermal(Closed Loop) E3Tracer 20.DREELLING LOG attach additional sheets if nethermal(Heating/Cooling Return) Other( lain under#21 Remarks) FROM To nFscwe WN wler,bn.dnes swumck n,a rain sin,
O r (�
4.Date Well(s)Completed:gAV ?1Well1D# ft. y2S ft
Sa.Well Location:
601W ft. ft _
Facility/0wnerN a Facdityll)#(ifapplicable) R R JF P 0 20
07
Physical Address,City,and Tap
JQA k1'A 2L RE14iARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslmiuutestseconds or decimal degrees:
(ifwell field,one Mang is sufficient) 22.Certification:
6.Is(am)the well(spPermanent: or Temporary Signature o Certified well Contractor au
By signing this form,I hereby cent-that the well(s)was(were)constructed in accordance
7..Is this a repair to an existing well: I )Yes or No with ISA NCAC 02C.0100 or ISA NCAC.02C.0200 Well Construction Standardr and that a
Ifthts is a repair,fill out kttown well construction informatio and, lata the nature of the copy°idt+s record has been provided to the well owner.
repair under 921 remarks 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ZS ( ) 248.For All Wells: Submit this farm within 30 days of completion of well
For multiple wells list aff depths ifdIerent(ample-3Q200'and 2®100) construction to the following:
10.Static water level below.top of casing: 1 c7 UP Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617.
11.Borehole diameter: din) 24b.For Infection Webs: 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: 1 1 construction w the following
(Le-auge;sty.cable,direct push 6c
Division of Water Resources,Underground Injection ConbroI Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of tub � � 24c.For Water SnDDly&Iuie iom Wells: Tn addition to send'mg the form to
�!!� the address(es) above, also submit one copy of this form within 30 days of
13b_Disinfection type: r '� Amount: !Ue'y 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 Resources Revised 2-22-2016