GW1-2022-09299_Well Construction - GW1_20221006

Print Form
WELL CONSTRUCTION RECORD(GW-1) For intemal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES I
FROM TO rDESCRWTION
WellCom etorName S
4518-A
tt �.
NC Well Contractor CenificationNumber 15.OUTER CASING(for multi-cased wells OR LINER if a livable
Aqua Drill,Inc. FROM TO DfAMETEtt 7INCiCNEss MATERIAL
/1 ft TO tl. in.
CorapanyNeme V
/�- ple-
16. CASING OR'T(JBING othermal dosefl-l0o
2.Well Construction Permit#: /�2�10 a FROM To DrenETx I TlnCKNESS MATERtAt
List all applicable well construction permits(r e.UIC,County:Stark Variance etc) ft. ft I hL
3.Well Use(check welluse): ft fL in.
Water Supply Well: 17.SCREEN
FROM1t TO DIAMETER SLOT SIZE THICKNESS MATERIAL
3Agticultural oblunicipallmlic & ft in.
Geothermal(Heating/Cooling Supply) dential.Water Supply(single) ft ft. in.
Industrial/Commercial DResidentiai Water Supply(shared) 18.GROUT
i—11nization. FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water supply well: ID ft, ft
Monitoring _Recovery ft ft
Injection well:
D. Aquifer Recharge OGroundwaterRemediation R IL
LGeothennal
ifer Storage and Recovery DSaiinity Barrier 1FRO9.SnAtND/GRTO PACK MATh� EMPLACIIKENTMETHOD
ierTest 13StormwaterDrainage ft ff
erimental Technology Subsidence Control ft ftthermal(Closed Loop) Tracer20.DRILLING LOG attach adds Tonal sheets ifnace(Heatin Cooh"agRetum Other( lainunder#21 Remarks FROM To DESCRIPRON mlor,Aortin coNrvck actu eta
%
4.Date Wel1(s)Completed: 9 �1' Weu ID# ft- 2 2S ft k
5a well Location: ft ft (r
/Vt,'kc S cGnt�-Y % ft
Facility/Owner Name IFacility lD#(if applicable) ft OC 1O V O Z
V81 B MMU d r• V"I to- ft ft
Physical Address.City,aadZfp ft it
ho`j,,�./_ 21.REMARKS
County I ^ Parcel Identification No.(P"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
34- 174 3Z'r�! IN go. 0 8 6 CI 2 W "_ q � �Z—
Signature of Certified Wen Contractor Dafe
6.Is(are)the weIl(s) Perman>rot or Temporary
rBy signing dro form,I hereby cowfy that the rv&(s)was(were)eonsmicted in accordance
7.Is this a repair to an existing well: Dyes orMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Consimctlon Standards and that a
If this is a repair,fill out Lvaim well construction infornrat'n and explain dte nature of the co
pY of this retard has been provided to the well owner.
repair under#21 remark section or on the back ofthirform.
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 if necessary.
wed' SUBMMAL INSTRUCTIONS
9.Total well depth below land surface: 22S (fk) 24a.For All Wells: Submit this form within 30 days of completion of well
For mnldple rvdk rut all depths ifdifferent(example-3@200'and 2@1M construction to the following:
10.Static water level below tap of casing: V(7 (ft) Division of Water Resources,Information Processing Unit,
If`"ate kvd is above Wig.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (m) 24h.For Infection Wells: In addition to sending the form to the address in 24a
Iru pR n/ above,also submit one copy of this form within 30 days of completion of well
12.Well constriction method:
C—auger.rotary.cable,daentposb,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Veld(gpm) Method of test: 116LC <eX'0 24c.For Water Supply&Infection Wells: In addition to sending the form to
9 the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: Amok l��L completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Departmeat of Environmental Quality-Division of Water Resources Revised 2-22-2016