GW1-2022-09701_Well Construction - GW1_20220510

MEN Id I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin 14:WATER'ZONES`.
FROM I TO DESCRIMON
Well Contractor Name ft. 7Lt fL q`
4518-A ft, is
NC Well Contactor Certification Number I&OUTER'.CASING ormniti cased wells ORMNER da
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
fL in.
Company Name e .16.1fe=CASING G OR TUBING: othermal closed-loop)
2.Well Construction Permit#: 0 y �g _ Zo2 FROM TO I DIAME= I TEUCKNM5 MAIERML
List all applicable well ca»struct/on permits(ce UIC,County,State,irarianee,etc)
ft. fL ia.
3.Well Use(check well use): fL
Supply Well: 17.SCREEN
Water Su
P FROM TO I DIAMETER I SLOTSIT.E THICKNESS I h1ATERIAL
Agricultural IOMunicipalt'Public ft. ft
Geothermal(Heating(Cooling Supply) gResidential Water Supply(single) tz ft, is
_ Industrial/Commerrial Residential Water Supply(shared) 18 GROUT
hri ation FROM TO MATERIAL O LACEMENTMETHOD&AMOUNT
fAquifer
ater Supply Well: Q ft. &
toring Recovery ft• fL
n Well: ft, ft.
Recharge OGroundwater Remediation
19.SANDIGRAVEL PACK ifs Ntable .
er Storage and Recovery Salinity Barrier FROM To MATERIAL EMFLACEMENTMETHOD
er Test OStormwater Drainage R. ft.
_ Expetimental Technology OSubsidence Control fL R
Geothermal(Closed Loop) Tracer 20.DRII3i1NG LOG attach additional sheets if necessary)
Geothermal(Heating/Coolin Return.) rJOthcr(explain under#21 Remarks) FROM To DESCRIPTION color,bnrdnen,soiv,nek type. rains etc.
O ft y S
4.Date Well(s)Completed: i3 Well EM R. 7 ft'
IL
tt
5a.Well Location:
k. ft
lyGS�fbn
Facility/Owner Name Facility ft' R
ry
1127 IPt 1
Physical Address,City,and Zip ft. fL " 4Y
)! ��tfA
21.REMARKS Ufa
L-�' �p
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
'J�e. 13Z S N . S 22 27 W
6.Is(are)the well(s) Permanent or OTemporary Signaffre ofCcrified Well Contractor Date
By signing this form.I hereby certify that the we/l(s)was(were)contacted in accordance
7.Is this a repair to an existing well: El Yes or �No with ISA NCAC 02C.0100 or lSA NCAC 02C.0200 Well Construction Standards and that a
If dds is a repair,fill out known well construction infonnation and explain the nature of the copy oflhis retard has been provided to the well auras.
repair wider 921 remarks section at-on the back of this form. 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 i GW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 70 (ft) 24a.For All Wells: Submit this fora within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �� Q* Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection Wells: in 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: FoAmf y construction to the following:
(Le.auger,rotary,cable,direct push,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) A Q" Method of test- 24c.For Water Suonly&Infection 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: 7 Amount: Z completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016