GW1-2022-09320_Well Construction - GW1_20221007

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
L Well Contractor Information:
Cameron BaZIR 114.WATER ZONES
FROM I TO DZ4CR1PTI0N
well ConnactorName, ?0� '
ft ft I
4518-A 7 It
NC Well Contractor Certification Number t5.OUTER CASQIG ar motti<ased wells OR LDIER if livable
Aqua Drill,Inc. r•ROM TO R DtAt1iE1ER rR TMCKNM MATERIAL
Company Name 16.DINER CASING ORTUBING eothermaldoeed-too
2 Well Construction Permit#: FROM TO DUMETER rHlcxivFss MATERIAL
ft
List all applicable well canshu cHon permits(71 a UIC Counts.Stag Vandi eta.)
3.Well Use(check well use): fL fL
Water Supply 1 Well: 17.SCREEN
FROM TO I DIAMt:1'ER I SLOT S[2E THICKNESS MATERIAL
Agricultural DMunicipditblic ft ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft
Industrial/Commemial Residential Water Supply(shared) 18.GROUP
—11nigration stoat TO nurERraL sMeLACEn>fit�t MErnoD rr AMOIrNr
Non-Water Supply Well: '0 ft' fL C tI
" Monitoring Recovery ft. %
Injection Well: it ft
Aquifer Recharge 00mundwater Remediation 19.SAND/GRAVEL PACK d cable
Aquifer Storage and Recovery Salinity Barrier FROM TO I blATERTAL EMPLACEMENT METHOD
i-Aquifer Test OStotmwater Drainage ft. ft
Experimental Technology OSubsidm=Control ft R
Geothermal(Closed Loop) OTiacer 20.DRILLING.LOG attach additional sheets irnece
R
FROM TO DF.SCRWMN color
Geothermal(Heating/Cooling Return) Other( Iain under#21 Reloads) naraa®.6omroctc a siu cec
w7 � fwe
4.Date Well(s)Completed: m Well ID# R �2� ft' AQ
fL %
Sa.Well Location: fL
ekyfts r _
ten fL � _= n R
Facility/OwnerN� Facility l0#(ifepplicable)
Ss2S Alin igLw ra. , 9 M & UUT o 7
Physical Address,City,and lip I
ft --
Y �N 21.REMARKS J
Gd II �n
County ParcelIdentifieationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 2L Certification:
3G.1719`3 N AO-1-74a83 w �v
6.Is(are)the well(s) Pkrmanent or IOTemporary Signature efCeTffflcd Well Conhactor Date
oy signing this form.T hereby cvilfj•that the w W(s)*us(were)constructed in accordance
7.Is this a repair to an existing well: lYes or __ No with!SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Contraction Standards and that a
gthfs is a repair,fill out known well construction informat' and explain the nature ofthe copy of this record has been provided to tbe,well owam
repair under 921 remarks section or on the back oftlrisfornt. 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 ifneccssaty.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 925 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereat(example-3@220,0'and 2 a@100) construction to the following.
10.Static water level below top of casing. 1' (ft) Division of Water Resources,Information Processing Unit,
("water level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.
24b.For injection Wells: Ia addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12 Well construction method: 12b Q� construction to the following
(le.—pr.rotary,cable,directpush,etc.) — F
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
MR.Yield(gpm) .5 Method of test: &<*eAff 24c.For Water SuDDIv&Injection 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 Amount: completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016