GW1-2022-09892_Well Construction - GW1_20221028

PrInt.Form.-.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information:
Cameron Sazin 14.WATERZONES`..
WellContmetorName FROnr TO DESCRIPTION
4518--A fr. 5
ft, ft,NC Well Contractor Certification Number
15.OUTERCASING.for multi eased-lVells OR LTNER'Gf a licdi[e :•• •
Aqua Drill,Inc. FROni TO DIA5=-R THICKNESS MATERIAL
CornpaayName In. o..�
-16.1NNER CASING OR G(ge6therintil-cloted-ldorl,
2.Well Construction Permit#: FROM I To I DIAMETER I TmrKNFSS niATFnIAi
List all applicable well eom&uctfon permits(te.UIC,CotarM State,Parlance,eta) ft It. In.
3.Well Use(check well use): ft, ft. In.
Water Supply Well: 17.SCREEN',
, '
Agricultural FROM TO DIAMETER SLOTS= THICKNESS MATERIAL 1 Municipal/Pub&c ft iw in.
Geothermal(Heating/Cooling Supply) (IResidential Water Supply(single) fy ft tn.
" hldustriaUCommercial �DResidential Water Supply(shared) 18.GROUT
irrigation FROM TO MATERIAL EN PLACEMENTMETMOD&AMOUNT
Non-Water Supply Wen: 0 ft. :0S ,ft 4/e
Monitoring 'Recovery fI, ft
Injection Well:
t} ft
- AgniferRechazge DGroundwaterRemediation
Aquifer Storage and Recovery (' '7,Salini Barrier 19•SAND/GRA�zLLPACK zfa Tica6fe .
_ 'L.Y ry FROM TO MATERIAL. EMPLACEhIENTML•Z'HOD
Aquifer Test 0StonneaterDminage ft. ft
Experimental Technology .Subsidence Control % ft
__Geothermal(Closed Loop) OTracer 20:DRIf f.ING LOG attach additional sheets tf necessary)
Geothermal(Heating(CooWe)Return) "; Other(. lain under#21 Remarics) mo O� -DESCRIPTION
PTION lor,hardaea,miVmdc a Mtn s�ate
ft.
4.Date Well(s)Completed: 16 9,well IM ft. l•35 ft , ' '
52.W-reeRLocation. ft. it
ft ft.
Facili /Owner Name ft. ft
9 °+.`• �� a�° L
tY /n] /J FacilityIDi=(ifapplicable)
2n a l sA// 'Uc ft, It OCT . 20 2
Physical Address,Ci%and Zip fL ft
ke4 21.RE11fARKS
County Pmzci identification No.(PIN)
5b.Latitude and longitude in degrees/nrimites/secouds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22-Cerfi&cation:
6.Is(are)the wells)1 ' ermanent or Temporary Signature afCerdfied WeIl Contractor Date
By sighing this form,I hereby certify that the well(s)was(were)constructed in accordance
7,Is this a repair o an crusting-*Yen: E3Ycs or,nd�No vita ISA NCAC 02C_0100 or I5A NCAC 02C.0100 W&Construction Standards and that a
Iffids is a repab;fia outknouvz nwll construction infonnatiaefr and explainrite nature ofthe copy ofthis record has been pravlded to the tuell otvaer
repair wider 1:21 remarks section or on the back of thisform
23.Site diagram or additional well details:
S.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 GW-I is needed. Indicate TOTALNUMBER ofwells construction details.You may also attach additional pages ifnecessary.
drilled:
4 SUBINUrTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells 11si all depths ifdifereni(example-3Ca 200'and 2Q100) construction to the following:
10.Static water level below top of casing: �€i� (ft) Division of Water Resources,Information Processing Unl4
Iftvaterlevel is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699 1617
11.Borehole diameter. Cu,) / 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �ilj���I i 'ld above,also submit one copy of this form within 30 days of completion of well
(i a auga,rotary,cable,airectpash etc-) �r construction to the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
[ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m l d
(gP ) Method of test: � 24a For Water SunDly&injection Wells: 1n addition to sending the form to
rr-• the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: /A22 completion of well construction to the county health department of the county
where constructed-
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resour= Revised 2 22-2016
I