GW1-2022-08944_Well Construction - GW1_20220919

_Print Form_
WELL CONSTRUCTION RECORD(GW 1) For btemal Use Only: i
1.Well Contractor Inforination:
Cameron Bazin 14-WATMZONFS
Well Contractor Name a ' ° .-..L,/ FMb' TO DESCRIPTION
IL ft.
4518-A SEP a 2022 Zos �. IL
NCWeUContractorCettificationNcmber 15.OUTTERCe4SIATG(for maiHeasedweUs ORLIIVER Ifa ►icable
�rliGi tC 1 �i�`C�va:1. Ut 4 FROrt TO DL4&SETEIt ' tffiCKNESS MATERIAL
Aqua Drill,Inc. �,,r 0
it. y e ft i iu.
CompanyName 16.DMRCASINGORTUBING( thermaldoseddoo
2.Well Construction Permit#. t:lll�(O� ]FROM TO DiAMElER TEUCEMESS MATERIAL
^^,,///`'
Llst alt applicable well cwatrucdon permits(i.e.UIC Countlt Stag Varlanc4 eta) % IL i In.
3.Well Use(cheekwell use): % + in.
Water Supply Well: 17.SCREEN
FROM TO I DrAMMR I SLOTS= I TRICKNESS I MA7ERL\L
3Agricultimll DMunicipal/Public R is
Geothernurl(Heating/Cooling Supply) JffResidenfl2l Water Supply(single) ft. ft
IndusWaUCommencM Residential Water supply(shared) 18 GROUT
11higation FROM TO MATERIAL EMPLACEMNT hMMOD&AMOUNT
Non-Water Supply Well: to R
Monitoring DRecovery R. ft.
lExperimental
tion Well;
uiferRechatge DGronmdwaterRemediationuifer Storage and Recovery �"'�Salioi B � 19.SANDlGRAVEL PACK tf a h'cabhe�p ty FROM TO MATERIAL EMPLAC04M METHOD
fTest 0St-raw-terDrainagett Technology OSubsidence Control ft ftothermal(ClosedLoop) E3Tracer 20.DRlLLINGLOG MAecessaiA
othermal(Heating/Cooling Return .Other(explainunder#21 Remarks) FRDIrtio TO DESCRIPTION(color.aoraa�,sotureck euta size Ma
ft &
15
4.DateWell(s)Completed: v Q /
r"(�Wellm# ft &
5a.Well Location: % ft
VrifOt/N�G �pt(,aJ� ft. ft
FacilitylOwnerName Facility
yll�D#(ifapplicable) & %
put— ff�Ml►t^ _ 0<I®/ Ar, ft. ft
PhysicatAddress,City,and Zip K• %
ZL REMARKS
County ParcelidentificationNo.(PIN)
5b.Latitude and longitude in degrees/tnlnutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
6.is(are)thewell(s) ermanent or IOTemporary SignaturcofCcr6fiedWell ontmotor i
By signing this form,I hereby eertifj that the uell(s)xnt{tirere)constructed in accordance
7.Is this a repair town existing well: I©Y¢S or .__ No with ISA NCAC 02C.0100 or 15ANCAC 02C.0200!Yell Construction Standards and drat a
Ifthis is a repair,fill out Imoxm well construction informati and erplainAke nature ofthe copy ofthirrecord has been provided to the nwil owner.
rq rwider#21remarkssectionareathebarkofdrisfo 23.Site diagramor additional welldetails:
S.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 SUBAN1TALINSTRUCTIONS
9.Total well depth below lead surface: !i 2 y4a,For All Wells: Submit this'form within 30 days of completion of well
For ' e ivelk 1W all rf ff ( p (a)2 (a)I 61 (4) p
lap! depdrs'di erent emm le-3`00'and 2 0 construction to the following:
10.Static water level below top of using: r b (M) Division of Water Reso Trees,Information Processing Unit,
Ifwaterlevel is above casing rise+/" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: _ �'G1Jry above,also submit one copy of this form within 30 days of completion of well
(i.e.auger;rotary,cable,d'aectpush,etc) construction to the following
i
Division of WaterResonrces,Underground Injection Control Program,
FOR WATER SUPPLCY,WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Will) 7 d Method of test: /f 24c.For Water Supply&Iniectioir 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:-9-10 Amount: completion of well construction to the county health department of the county
where constructed.
FormGW-1 NorthCarolina Department of Environmental Quality-Division of Water Resources; Revised 2-22.2016
0

Nrint"Farm
WELL CONSTRUMON RECORD(GW-1) For Intemal Use Only:
L Well Contractor Information:
Cameron BaAn 14.WATER,ZONES I
WCliCotltractarNamc i ' L N " FROM TO DESCRIPTION
E, `_ E-- 20 S It. ft. M
459 8-A
NC Wet]Contractor Cer ficatioaNumber v r P d v0 2022 lar.OUTER CASING(for multi-cased Was) a livable
Aqua Drill,Inc. , PROAt TO FERR 7rit ' TffiCRNFSS MATERIAL
Inr'r�;��...rn �r�c:^.:...;.t�� ir,;r Name i O ft. 5/O it: ',iri
Com an
p y t�1C/�(3G 16.INNER CASING ORTITBING(eotttermaldosed-loo
2.Well Construction Permit#: 014p FROM TO nfatvIET a - TMCE(NM I MATERIAL
List all applicable well construction po7dis p',e.UIC,County,State,Variance eta) (L R to.
3..Well Use(checkwell use): ft. IL in.
Water Supply Well: 17.SCREEN
3Agr_ FROAf TO DIAMETER ,SLOTS= TMCKNESS MATERIAL
cultural Municipal/Public % hL
Geothermal(IieatirWCooling Supply) jffResidential Water Supply(single)
ft. R in.
htdustrial/Commercial OResidential Water Supply(shared) I&GROUT.
ITnigation FROM TO MATERIAL ENIPLACM"NTMETROD&AMOUNT
Non=Water Supply Well: JO fL t fL G i
Monitoring -Recovery ft. %
Injection Well:
tuferRech fL IL
Recharge OGroundwaterRemediation 19.8AND/GRAVELPACK ifa livable
quifer Storage and Recovery Salinity Bar7er )iRODi TO MATERIAL EMPLACEMENT METHOD
3Aquifer E]StoimwaterDrainage fL &
Experimental Technology OSubsidence Control fL fw
Geothermal(Closed E3Trdcer 20.1)MI NGl;OG'attachad&&nal'iheetsifo;
Geothermal(Heating(CoolingReturn) � .. Otber(explaiuunder#21Remarirs) moat TO DESCRIP[ION.eolor,6atdness,solUmek asiuc[e
Q ft. ft
4.Date Well(s)Completed: v r �WellID# fL
Sa.Well Location: R. ft.
Facility/OwnerName Facility IDA(ifapplicable) ft_ ft.
It, fL
PhysicalAdilmss,City,andZip m fL
G ). 21.REMARKS ;
County ParcelIdendficationNo.(PIN)
5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees:
(ifwcll field,one Mang is sufficient) 22.Certification:
3�e_yG1f,.o >v_ p.99G W �r/,r aV24
6.Is(are)the welf(s) ermarent or IOTemporary Signature of Certified Well'Contractor { DAc
7— By signing this form,I hereby ceWfi-Hiatt tyre welf(s)crm(were)constructed in accordance
7.Is this a repair to an existing well: I�Yes or No with 15A NCAC 02C.0100 or 15ANCAC.02C.0200 iveil Conunrcaon Standards and that a
Ifthis is a repafr,Jill out/crown ivoU coirstructioninforma, and explain.d nature ofthe copy ofthisrecord has been provlded to the uWl owner.
repair under#21 reivardssection or 6n the bank ojtlrisjo 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Close&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 a:ft&additional pages ifnecessary.
drilled SUBMITTAL INSTRUCTIONS i
9 Total well depth below land surface: ZZ 00 24a.For All Wells: Submit this form within 30 days of completion of well
Fortmriaple ivells ibt ail depths ffdll ferent(example-3()a2000'and 2@100) construction to the following:
10.Static water level below top of casing: e r b (ft) Division of Water Resources,Information Processing Unit,
Ifwarer fever is above casing;rise'+
1617 Mail Service Centey Raleigh,NC 27699-1617
f, ;
11.Borehole diameter. (ia.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12 Well construction r�rGN�V above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable;&met pusly etc) construction to the following.
Division of WaterResoarces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mal Service Center,Raleigh,NC27699-1636
13a.Yield(gpm) 7 Method oftest: /1 24c.For Water SuDnly&Iniectiin 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: 'OZ' Amount: r completion of well constriction to the county health department of the county
where constructed.
FormGW-1 NorthCamlinaDeparhnentof Envimtmrental Quality-Division of WaterResources Revised2-22-2016