GW1-2022-09074_Well Construction - GW1_20220923

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor information:
Cameron Bazin 14.WATER ZONES
Well Comractor Name FROD1 To I DFSCRWTION
4518 A n ft.
NC Well Contractor CenificationNumber i) tti 15.OUTERCASING(formntHceswlwells ORLTNER a licable
SEPAqua Doll, Inc. 202 FROM TO DtAMLTER TRiCiQ- MATERIAL
CompanyName i .-.,1 �i, i': Li f 0 R. ft in.
3! 16.DRUR CASING ORTUBING thermalclosed400
2.Well Construction Permit FR0t11 TO DIAM6RER THICKNESS MATERIAL
List all applicable well construction permits(i.a U1C County.States Parlance,eta) ft. R• ' 1.
3.Well Use(check well use): R f in.
Water Supply Well: 17.SCREEN
FROai TO, DIAMETER SLOTSIZE nUCKNESS MATERIAL
gricudhural DMuniaipaVPublic (t, I in
Geothermal meating/Cooling Supply) Residential Water Supply(single) f g in.
IndustriaUCommelaial Residential Water supply(shared) I&GROUT
7-hrigation. FROT.1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O $ 21 R
Monitoring Recovery & &
Injection Well:
L.1� tt.
Aquifer Recharge Groundwater %Remediation 19.SAND/GRAVEL PACK(if a Hcable
:-)Aquifer Storage and Recovery QSaiinity Barrier FROM TO MATERIAL I EMPLACEMt M METIiOD
Aquifer Test OSto>mwaterDrainage M %
Experimental Technology OSubsidence Control & fR
Geothermal(Closed Loop) E)Traeer 20.DRILLING LOG attach additional sheets if ne
Geothermal(Heating/Cooling Return) MOther( lain under#21 Remarks FfL
To IL
DEscRlPrcoN color Lnsaaen,solutock sa size etc
4.Date Well(s)Completed: Weil ID#5a.Well Location: % %
FRty/OwuerName v Facility ID4(if applicable)
2�Z T�G Ar n=15s'lff� ft
Physical Address,City,and Zip it. IL
"i Vl0 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minatea/seconds or decimal degrees:
(if well field,one latitong is sufficient) 22.Certification:
35,3?78/ N $0.43qco w
6.Is(are)thewell(s) ermanent or Temporary Sigaa me ofCcr ied Well Contractor D
By signing this form.I hereby cerih,that the weB(s)wvs(were)constructed in accordance
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7.Is this a repair to an existing well: )Yes or o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known ivell construction informati and esphrin the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 ranarls section or on the back oftkusform. 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: r (R) 249.For All Wells: Submit this fora within 30 days of completion of well
For multiple wells list all depths#different(example-3Qa 200'and 2Q1001 construction to the following,
10.Stade water level below top of casing: go (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+j 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1� (in-) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method- above,also submit one copy of this form within 30 days of completion of well
(i.e,auger.,rotary.cable,dia�xpush,etc) construction fn the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield
(gPm) 0 Method of test: i 24c For Water SuDDIv&infection Wells: In addition to sending the form to
the address(ea) 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.
Farm GW-1 North Carolina Department of Fmvironmental Quality-Division of Water Resources Revised 222 2016