GW1-2022-09891_Well Construction - GW1_20221028

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WELL CONSTRUCTION RECORD(GW-1) ForTntemal Use Only:
1.Well Contractor Information:
Cameron Bazin _..'- . . . :..:::. . .
-.14:wA'fER'zoNES••..
FROM I TO DESCRIPTION I
Wel[ContractorName
4518-A FPJJ ft. ft [T
\'C Well Contractor Certification Number 15.OUTER-CASING"for mali%easeS wells OR'L'1IVER Crf a lieatile
Aqua Drill,lnC: FROM To DrAMETER xmcla�ss MATERIAI
49
ft, Yo tt In.
CompanyName ^�Z .16.INNER CASING"URTUBING eothermalclesed-Ido
2.Well Construction Peralit#: /�/ MONT TO DLAkA=R TffiC[QIFSS PJAIMMIAL
List aU applicable well construction permits`Le.WC,Coanry State Parlance etc.) ft• ft•. ID.
3.Well Use(check well use): ft ft. rn
Water Supply Well: 17.SCREEN
PPY FROh1 TO DIAMETER SLOTS[ZE • Tii1CKNFSS 1rATER1AL
Agricultural 0NfunicipaUPublic ft. ft in.
Geothermal(HeatinalCooling Supply) Residential Water Supply(single) fL IL
Industrial/Commercial Residential Water Supply(shared) 1&GROUT
-.-lrri atioa FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non--Water Supply Well: ft 2
Monitoring rMID. cry ft ft
Injection Well: ft it
Aquifer Recharge DGroundwaterRemediation
I9.SANDJGRAVELPACK rfa Ticable .
Aquifer Storage and Recovery Salinity Barrier -FROM To MATERAL EMPI.AMWENTMEMOD
Aquifer Test OStonnwaterDrainage ft' ty
13xperimental Technology EiSubsidence Control ft.
Geothemmal(Closed Loop) OTtacer 20:DRTLLINGLOG attadradditionalsheets'ifnecess
_ FROM 70 DESCRD''rtON rntor,6nrdaess.miVmrlc - e; is sir.eke)
:Geothermal(Heating(CoolingRetnm.) .� Othcr(cxplainubdrsn2l Remarks) ft. ft S d
4.Date Wells)Completed: 1 O l&V Mell IEW. ft, !PS ft.
fL it
Sa.Well Location:
Facility(Oivner llama /n/� 1 FaacilirylDR(if applicable)
ft' ft
tali V&-A T, aOfillnGtG rr f[. 022
Physical Address,City,and Zip �— ft tt i15�'Y ,✓ n )�J is rl!
d kG 2 KR
1.REKAR ,
County Parcel Identification?vo.(PIN)
5b.Latitude and longitude in degreeslminutestseconds or decimal degrees:
(ifivell field,one Tadlongis sufficient) 22.Certification:
6.Is(are)the well '_.$) Permanent or OTemporary signature Certified Well Contrauar Date
BA signing this form,I hereby certify that the ivell(s)was(were)constructed kn accordance
I.Is this a repair to"existing well: E3Yes or,'_ o with ISA NCAC 02C-0100 or 15A NCAC 02C.0200 Well Constniction Standards and dint a
If this is a repah•,fig out Imam cell construction informs n and explain the nature ofthe copy ofthis record has been provided to the well marrer
repair under n21 remarks section or on the back ofthirform. 23.Site diagram or additional well details:
i'. You may use the back of this page to provide additional well site details or well
1: 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details.You may also attach additional pages if necessary.
construction,only 1 GsW-1 is needed. Indicate TOTALNUMBERof wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 195 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For muldple wells list all depths ifdiffereat(erample-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: YO (ft) Division of Water Resources,Information Processing.Unit,
lfwater level is above casing.ise+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection 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: w" l I- construction to the following
(i e.auger,rotary,cable,duectpush,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699 1636
13a.Yield(gpm) `S Method of test~ 7 j i� 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: Ud completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016