GW1-2022-08915_Well Construction - GW1_20220912

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin MWATERZONES E.
Well Contractor Nam FROM TO I DESCRIMON
ft. it
4518-A
ft. fL
NC Well Contractor Celti6cationNttm6er 1'.OUTER CASING(for multi-cased wells OR LINER s iicable
Aqua Drill,Inc- FROM TO MMETER T�QttYESS MATERIAL
0 [t 90 ft. 6 in. PLC
CompanyName A�--i r'5 l -,04-J 16.INNER CASING OR TUBING othermal closed-loo
2.Well Construction Permit#: FROM To I DIAMETER THICENESS MATERIAL
List aU applleable wea cmustrm d.-permits f e WE County,State.Variance,eirz) it fL Ia
3.Well Use(checkwell use): fL %
Water Supply Well: 17.SCREEN
FROM TO DIAMETER: SLOTSME IMCKNESS MATERIAL
Agricultural Munieipal/Public Tars& 1 S 2 1O'' .b
Ale-
30ccithermal(Heatiag/Cooling Supply) Residential Water Supply(single) g, In.
htdtlstrial/Commeroial ORwidentialWater Supply(shared) 1&GROUT
hri 'on FROM TO MATEMAL EMPLACEMENT METHOD&AMOUNT
Non-Water
(HeatinglCootiDg Return Other( lain under#21 Remarks v �on-water Supply well: O G
Monitoring Recovery 0 ft. fL
Injection Well:q urge �GmuadwaterRemetliation
A uifer Rech 19.SAND/GRAVEL PACK d licable fL %
Aquifer Storage and Recovery Dsalinity Basler FROM To MATERIAL EMPLACEMMU METHOD
Aquifer Test [3StomnwaterDrainage ft. ( 5 .2. S�
Experimental Technology OSubsidence Control & fL
Geothermal(Closed Loop) 1ITracer 20.DRII LU9G LOG attacb additional sheets R necessary)
FROIet TO DESCRM11ON color,hutches%sollhaek e, nstye.etc
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4.Date Well(s)Completed: ZZ Well ID# m ft 174 &
Sa.Well Location: ft. fL
tL ft:
Facility/OwnerName Facility WO(Vapplicable)
!7a �Ya�S �d Thor�►c+Sdr `(a, /1/L `� °` - -
Physical Address,City,and Tap @. fL - 'r -
2LREMARKR <<
&V dS - -
Caurty Parcel Iden[ificationNo.(PIN)
Sb.Latitude and Iongiitude in degrees/minutesrseconds or decimal degrees:
(ifwcll field,one Iaglong is sufficient) 22.Certification:
35, Mp /y N S©• 15 01 W 2z
6.Is(are)the well er umneut or F3Temporary SignauA ofCcrtified well Contractor Dale `I
By s(gning this form,1 hereby c-h,that the sveU(s)wvc(mere)—tructed in accordance
7.Is this a repair to an existing well: IOYes or MO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consimcdon Standards and that a
Ifthis is a repair,fill out known well construction igformatw and esplainlhe nature ofthe coN ofthis record has been provided tD'the well owner
repair rider#21 remarks section or on the back of ddrform. 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: SUBMfITAL INSTI CTIONS
9.Total well depth below bald surface: 1?C 00 24a.For All Wells: Submit this form within 30 days of completion of well
For rmda'ple ivells list all depths ifdifferent(example-3(4200'and 2©1M construction to the fallowing:
10.Statie water level below top of casing: yo (fL) Division of Water Resources,Information Processing Unit,
Ymeer level is above casing,use-+- 1617 Mall Service Center,Raleigh,NC 27699-1617
1L Borehole dia 101, (in.) 24b.For Infection Weds: In addition to sending the form to the address in 24a
above,also submit one copy of this fora within 30 days of completion of well
12.Well construction method: f�'Gt construction to the following:
(Le.anger,rotary,cable,tl—push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Center,Raleigb,NC 27699-1636
13a.Yield(gpm) Method of best: 24c.For Water Supply&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 constructed.
s
Foln GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2,22 2016
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