GW1-2022-09702_Well Construction - GW1_20220510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use only:
I.-Well Contractor information:
Cameron Bazin 14.WATER ZONES'.
FROM TO DESCRIMON
Well Contractor Name 7as g, a fL Q�
4518-A tt. / ft.
NC Well Contractor Ceitification Number M OUTER CASING or muUi-cas4i!wells OR LINER if a Wable;C
Aqua Drill, Inc. FROM ToI nrnMETER TtncxivEss tuAtEluat
it. I Y00 % 41� in.
Company Name Ct n p ^ n� 16.INNER CASING'ORTUBING: gebthermalclosed-ldo
2.Well Construction Permit#: 7 bJ FROM TO I D]AMLTER ITffiCIOYESS MATERIAL
List all applicable wall construction permits fle.UIC,County,State.Mariatum etc) R, to.
3.Well Use(check well use): ft. fL in
C
Water Supply Well: FROM TO I DIAMETER SLOT SIZE I TSICKM MATERIAL
:)Agricultural I0Mmricipal/Public it. fL in.
Geothemlal(Heating(Cooling Supply) Residential Water Supply(single) fL IL is
Industrial/CommercialReffesidential Water Supply(shared) is GROUT
RIrrigation
FROM TO MATERIAL EMPLACp,MENTMETROD&AMOUNT
Non-Water Supply Well: ft. 2 .fL t
Monitoring DRecovery ft. fL
Injection Well: R. %
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVII.PACK Sa Ucable .
Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL EMPLACEMENTMEMOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology OSubsidence Control n• R•
RGeothcrmal
Geothermal(Closed Loop) Tracer 20.DRILLING LUG attach additional sbeets if necess(Hcating/Coolin ..Return) Other(explain under#21 Remark FROM s) TO DESCRIPnONcolor hnedneM soiltroekin Size,ate.ft. 3� ft
4.Date Well(s)Completed: � Fell ID# O R' S R'
R. tt
5a.Well Location: IVED
fL
Facility/Owner Name 9 FacilityM4 fapplicable) R' h'
/l21 p�i.l6� �1. �'r�t%li�(/C ft fL MqY
fL
Physical Address,City,and Zip LIM
R.
2L REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
34 13 5S N �• SZ�2 W �l
6.Is(are)the wetI(s),0Permanent or Temporary Siganture of Certified Well Contractor Da
twl
By signing this form,I hereby eerlify that the rvell(s)Tsar(uw4 constructed in accordance
I.Is this a repair to an existing well: E3Yes or VfNo with lsA NCAC 02C.0)00 or l5A NCAC 02C.0200 Well Construction Standards and that a
If tiuis is a repair,Jill out knoxn well constntction information and explain the nature of the copy ojthis retard Iran been provided to the Well tnvner.
repair under 921 ramar/ns section or 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. indicate TOTALNUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ��S (R-) 24a.For All Wells: Submit this foma within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200*and 1@1001 construction to the following:
10.Static water level below top of casing: �i+ (%) Division of water Resources,information Processing Unit,
if ivater level is above caring.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
�,, �t above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rt.Y A /1 construction to the following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Resources,lioderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: A'14� 24c.For Water Sunnlv-&Iniection 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
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016