GW1-2022-09330_Well Construction - GW1_20221007

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WEU CONSTR.UC HON RECORD(G --I) For rnteraal Use Only:
1.Well Contractor information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A go ft fL
ft ft
NC'Well Contractor Cer6ficationNomher 15.0UTRR CASING(for mul0-cased wells OR I INER�f a licable
Aqua Drill,Inc. FROM To DrAaIEfER THICKNESS MATERIAL
p e. 135 ft. G in. C,
CompaayNirme
3^' 16.INNER CASING ORTUBING closed-l000l
2.Well Construction Perrmt##: / FROM TO DIAMETER I TlnCiaaess FMATERLAL
Ltst all appltcabfe Heft eoustrudiongermils f e UIC,Cotuid} Slats Yarloncr;eta) ft In
3.Well Use(checkwell use): & fL in
Water Supply Well: 17.SCREEN
_ FROH TO DIAMETER SLOTSr2E- THICKNESS MATERIAL
rxtltnral OMunicipal/Public & f{ in
Geothemral(Heating/Cooling Supply) 17Residentid Water Supply(single) fL JE in
-hrdustnal/Commereial Residential Water Supply(shared) 1&GROUT
—)Jnigation FROM TO—, MATERIAL . EMPLACMIENT METHOD&AMOUNT
Non-Water Supply Well: ft. 2( f6 G� P
Monitoring ORecovry & ft
Injection Well: '
fL ft.
Aquifer Recharge 13Groundwater Remediation
19.SANDIGRAVELPACK(ifavolicableI
Aquifer Storage and Recovery OSaliniiy Barrier FRoOI To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStammaterDminage rL fL
Experimental Technology DISubsidence Control ft &
Geothermal(Closed Loop) 13Traoer 20.DRILLING LOG attach additional sheets if nee
-`Geothermal(HeatinglCooling Retnm) MOther(ex lain Under#21 Remarks) FROM TO DESCRIPTION color hardncu.sv1Vreck rain size,eta!
0 ft- 10 EL5ta,l,L.
4.DateWeli(s)Completed: ZY 2L Well ID# (D ft '- '
'..
Sa WellLocation:
��fy ft. ft.
t^^ P 27-0 & ULI 0 7 707
Facility/Oew�nlejruNamc FaclityIM(ifapplicable) & &
QZ-11 INA ft. ft.
Physical Address,City,and Zip fL ft.
S 7`o kA 21.REMARKS
County' Parcel IdeatificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Wong is sufficient) 22.Certification:
34, Y S32Y N 80,21Q67 W 2Y�Z
/ 6.Is(are)the well(s) Permanent or IOTemporary Signature ofCcrtified well Contractor Date
f/I By signing this for,I hereby certify,that the tvell(s)was(were)constructed,in accordance
7.Is this a rep o an existing well: IOYes or ZINO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 JVdl Construction Standards and that a
Ifthis is a tepatr,fill out latoiva welt cansbuction it formatio and explain Use nature ofthe ropy ofihis record has been provided to the well owner.
I repairunder#2lremarkssectionorouthebackofiltisfort. 23.Site diagram or additional well details:
I8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pop to provide additional well site details or well
construction,only 1 GW-1 is needed-Indicate TOTAL NUMBER of wells contraction details.You may also attach additional pages ifnecessary.
drilled. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (7 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For ma&a'ple wells 1Walldepthsfdijferant(example-3Q200'and2g100) construction to the following.-
10.Static water level below top of casing: O (ft) DiAsion of Water Resources,Information Processing Unit,
1 11.B r leveloreholea diameter.above cast. use 1617 Mail Service Center,Raleigh,NC 27699-1617
1.B (m.) 24h.For Infection Wells: In addition to sending the form to the address in 24a
j above,also submit one copy of this form-within 30 days of completion of well
1-7-2.Well construction method: `e t 000^i
(Le.auger,ro construction to the following:
g rotary.Calfte directpush,er<> T—
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) Method oftest°` _K, %6 LGT- 24c.For Water Supply&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: A mo completion of well construction to the county health department of the county
where constructed.
FormGW-I ttnvitnnmtntal Quality-Division of WaterResources Revised 2-22 2016