GW1-2022-09232_Well Construction - GW1_20221003

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WELL CONSMUC HON RECORD(GW 1) For Internal Use Only: -
1.Wen Contractor Information:
Cameron Bazin
14.WATER ZONES
Well Contractor Name FROM TO DESCRmTIox
451&A 0$ ft.
NC Well Contractor Certification Number
Aqua Drill Inc. 15•OUTSR CASING(for multi-cased wells ORLDR R a &cable
q FRont TO DIAMETER THICKNESS MATFItU1L
Company Name �2� in. PW—
21Y/ S 16.INNER CASING ORTUBING othermatdosed-loo
2.Well Construction Permit#; FROM I TO DIAMEIER I TRIcxivEss MATERIAL
List all applicable well eotutmetion pemats ra UIC;Cover} Stag Yoriance etc) ft ft is
3.Well Use(check well use): tt. ft: in.
Water Supply WeU: 17.SCREEN
• Agricultural oMtmicipaVPublic FROM TO DIAMETER SLOTSIZE TAICKhTaSS MATERIAL
fL
ft �
-Geothermal(HeatinglCooting Supply) �Residenfial Water Supply(single)
Industrial/Commercial 3.
Residential Water Supply(shared) 1S.GROIIT
i Irri lion FROM TO MATERIAL EDtPLACZMF-T METHOD&AMOIM Non-Water Supply Well: O ft. L 3
Monitoring ,- Recovery R
Injection Well:
Aquifer Recharge C)GroundwaterRemediation R
Aquifer Storage and Recovery ElSalinity Barrier 19.SAND/GRAVEL PACK Ilcable
FROM TO MATERIAL =EIMPI"ACEME�NT.METHOD
Aquifer Test OStt rmwater Drainage fL fL
Experimental Technology Subsidence Control % it
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if nee
Geothermal eaflnP�Cooling Return) , . other(explain under 921 Remarks) FROM To DESCRIPTION color,hordnea,col mek 'n SEM eta
0 tZ Ito 8.
4.Date Weli(s)Completed;9ZVWen D)�# (Lp tt S fL Rook
5a.Well Location_: L R fL
JFL ft.
FacilitylOwn Name Facility ID#61'app(icable) & ft
r'
Utmak fL- �d LULL
PhysualA ss,City,andZtp fL tZ �lliCiifiic3;;`:1 '�r,
(�Gl✓� '� 11.tr>ttseurrs ",}un
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(ifweli field,one latnong is sufficient) 22.Certification:
3S. 7 2- hr $o. 47"t w 4 22 6.Is(are)the well
(s)�?ermaneat or (Temporary Si of a eIl Contractor Date
83,signing this jomr,I hereby cerufp that Ire wellfs)wm(were)contacted in accordance
7.Is this a repair to an existing well: DYes o*�No with ISA NCAC 02C.0I00 or ISA NCAC 02C.02001t'eff Consfmcaon Standards and that a
lfthis is a repair,fill out known hell construction informs on anted explain die nature of the -PY afthis record has been provided to the will owner.
repair wider#21 remarla section or on the back ofAisjorm.
23.Site diagram or additional well details:
9.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 weU
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells censtrumon details. You may also attach additional pages if necessary.
drilled:
SOS
9.Total well depth below land surface- SUBMITTAL INSTRUCTIONS
)�
Formultip►ewellslistandepthsifdifferent(aromple-g(a)I00 and2Q1003 24a.For AIf Wells: Submit this form within 30 days of completion of well
construction to the following.
ftv Static water level below top of rasing:__ G A) Division of Water Resources Information
ljrwter level is above casing,rote`+"� r Processing Unit,
6
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
(m.)
24b For Injection Wells: In addition"to sending the form to the address in 24a
12.Well construction method: �+z4A'k above,also submit one copy of this form within 30 days of completion of well
0—auger,rotary,cable,direct push,etc) construction to the following:
FOR WATER SUPPLY WELLS ONLY; Division of Water Resources,Underground Injection Control Program,
A/�� 1636 Mail Service Cent,Raleigh,NC 27699-1636
13a.Yield(gpm)_ Method of test: " - 24c.For Water SuDDhi&Infection Wells: In addition to sending the form to
13b.Disinfection type: Amonm: p the addresses) above, also submit one copy of this form within 30 days of
completion Of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of P.nvironmeaml Quality-Division of Water Resources RevisWL22-2016