GW1-2022-09554_Well Construction - GW1_20221021

WELL CONSTRUCTION RECORD(GW-11 For Intemal Use Only:
I.Well Contractor Information:
Cameron Bazin 14:waxl It ZONES'-..
Well Contractor Name FROM TO I DESCRrmoN
4518-A
tt. ft
NC Well Contractor Certification Number
15.OUTERCASING'formalti-cascil�ivelis ORL'11�R'Gfa Ilt�tile
Aqua Drill,Inc. FROM To DLINIETER THICtQVESS L
1 ft. ft t in. r
Company Name
•16.INNER CASING ORTt7BING,( 'thermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MAT RML
List all applicable nzll carrtmction permits(i a WC,County,stag Variance,etc) H. ft
3.Well Use(check well use): D In.
Water Supply Well: 17.SCREEN,:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipaUPublic -ft. M in.
Geothermal(Heating/Cooling Supply) [3Resideatial Water Supply(single) tZ ft is
Industrial/Cornmercial DResidential Water Supply(shared)
18.GROUT
Ini ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 M Z C`l
Monitoring DRecovery ft. IL
Injection Well:
tL St
Aquifer Recharge DGroundwaterRemediation 19 SAND/GRAVEL PACK ifa 1i¢able .
Aquifcr Storage and Recovery OSalinityBarrier FROM To I MATERIAL I EMPLACEhTENTMETHOD
.- Aquifer Test OStormwaterDrainage 0• im
Experimental Technology OSubsidence Control M ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if ne
Geothor mal(Heating Cooling Return) Other(explain under#21 Remarks) rROM To DES(MMON(miar ev hardn .solttracktypt6 grain slur etO
j FG o it, Slat t >
4.Date Well(s)Completed: (� Well ID# � Js ft
52.Well Location: M n'
>3 ra ft ft.
� � S�o n�Facility/O Acr Name � 11 Facility IDg(if applicable) ft rt.
Lt(G 1..
i�nf try ft ft.
Physical Address,City,and Zip R' ft
� 2L REMARKS
Y�� r.n
County Farm]Identification No.(PIN) `:, '�-V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelll field,one I/et/lorng is sufficient) 2 (, 22.Certfficat�ion:3bi�/(V N am.�/ ? W
6.Is(are)the well ... ermanent or Temporary Signature of Certified WellConuactor Date
By signing this form.I hereby caWfy that the rveII(s)ttvs Orere)canstruMed in accordance
1.Is this a repair to an existing well: ElYes 0�No wish 15A NCAC 02C_0100 or 15A NCAC 02C.0200 Well Construction standards and that a
Ift/ds it a repair.fdl out lanowrr nell construction infonnatl000,,,(((���,,,(((anndd erp/aiu the nanve ofrhe wpl'ofrhis retard has been provided to the well owner.
repair under#21 remarlcc section or an the back ofthisfotm
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 OW-1 is needed. Indicate TOTALNUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface 62 5' (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
Formultiple we.IIa list all depths y*&flerent lexample-3@200'and 2@1001 construction to the following.
10.Static water level below top of casing: I M) Division of Water Resources,Information Processing Unit,
Ijtwter level it above casing,usej+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
���pv�/ above,also submit one copy of this form within 30 days of completion of well
12 Well construction method
construction to the following
ri.e.atcger rotary,cable,dit-tpusb,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699 1636
13a.Yield(gpm) 5 Method of test: t/ ,l7 24c.For Water Supply-&Iniection Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this foam within 30 days of
13b.Disinfection type: / Amount: 'Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dcpadmcnt of Environmental Quality-Division of Water Resources Revised 2-2b2016