GW1-2022-09230_Well Construction - GW1_20221003

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WELL CONSTRUCTION RECORD((;W 1) For intemal Use Only. j
I.Well Contractor Information:
Cameron Bazin
14.WATER ZONES
Well ComractorName FROM TO DFSCPjrrfoN
451&A �- D-
tl. ft
NC Well Contractor CertificationNwmbw
Aqua Doll Inc. 15.OUTER CASING(formulticasedwells OR LINER fa Ucable
Q FROM TO DIAMETER TIRCKNESS MATERIAL
Company Name O R' b in- G
16.RMR CASING ORTUBING( I thermal dosed too
2-Well Construction Permit#: t FROnr To DIAMETER TxiCHMS MATERIAL
List al!'appflcabfe well construction pesmits(r.e U!C Cmmt}:Stag YariancG e�m) & fit to
3.Well Use(check well use): ft fT: In.
Water Supply Well: 17.SCREEN
Agriculturd FRO51 TO DIAMETER sLOTsIZE TRTCKNFSS MATERTAL
DMunicipaVPublic fL � �
Geothermal(HeathWCoolirlg Supply) idential Water Supply(single)
/— fit ft. hr.
lndustrial/Commercial E3Residentiai Water Supply(shared)
irri tloa FROM
GROUT
FROBI TO MATERWL EMPLACEM TNT hIETV01)&AMOUh-r
Non-Water Supply well: O � �
r
ing Rom , ffi
Well:
Recharge 0GroundwaterRemediationStorage aad 19.SANDlGRAVELPACK Usable""^"`-+7 �SaflailyBSffje< FROM TO MATERIALEMPLACEMEMI'MEITIOIITest [3Stomtwater Drainage iL fitental Techaulogy Subsidence Control g
mal(Closed Loop) DTiacer 20.DRILLINGLOG attacNionalsheetsal(Heatin COoGng Return Other(e lain under#21 Remadcs) zTtont TO DEscRlrrloN color hardness,wWroek -a sire-etr_
0 JFL 01*
4.Date Well(s)Completed: well m# ft fL
5a,Well Location:
n R. ft. � 'r Rom-.. F-� "
rwility/Owner ame p f a r t
FacWq UT#(ifapplicable) ft. R -
ft n
(!' sJ
_
Zan
Physical Address,City,and zip g k.
- Iko WAA 21.REMARKS '
County Parcel Iditaffi atioallo((PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
6FwcII field,one 1et/long is sufficient) 22.Certification:
3S. 76(G2 N ao-I719(
6.Is(am)the well(l6ermanent or DTemporary Siga�fmc ofCcrtifiuxi Weer D e
7.IS this a repair to an e ' well By signing thfs form,!hereby�,that the Ive IN was(were)constructed In accordance
ting I�IYes Ad.
o with!SA NCAC 1.0100 ar 15A NCAC 01C.0200 Wdl Construction Standards and that a
lfth&isarepair,fifoutlauosvnrveucansinwdoninformalphtin the nature ofthe copy ofthis record has been provided to the sirll owner.
reFair under 921 remarks section or on the back ofthisform.
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 censtiuction,details. You may also attach additional pages ifnecessary.
drilled-.
�e UBMITTALINSTRIICTI
9 Total well depth below land su S ONS
rface: !�4
For muhiple wells list all depths ifdifferem(eurmple-3Q200"and 2®I005 (R-) 24a.For All WeIIs; Submit this form within 30 days of completion of well
construction to time following:
10-Static water level below top of casing:ljswter level is above caring.use 00 Division of Water Resources;Information Processing Unit,
•=F"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. OIL)
/� 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Q O fC(j4-1/ above,also submit one copy of this foral within 30 days of completion of well
Cam.auger.mtaty,cable,direct push,ac) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Undetgry nd Injection Control Program,
` c 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) 7 Method of test: 7# 24c.For Water S11113 &Infection WeUs: In addition to sending the form to
13b.Disinfection type: the address(es) above, also submit one copy of this form within 30 days of
Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Depanmeat of Envimnmenrai Quality-Division of Water Resources Revised 2-22-2016