GW1-2022-09945_Well Construction - GW1_20221031

Pr•iiii:.Form... .:.
WELL CONSTRUCTION RECORD(GW 11 For Internal Use only: —---
I.Well Contractor Information: f
Cameron Bazin 14:.wATER'zoNES.-
Well CoatractorName FROM TO DESCRIPTION
4518-A ro
ft. fL
NC Well Contractor Certification Number
Aqua Drill,Inc. 15.OUTER.CASlNG`formulti-cmed'. OR'LlNM>fs 4mtile
FROM To DIAMETER THICKNESS tvrATIE,RrAL
CompanyNatne it• s'� f4 in. V cl
�17 16 INNER CASI MINIG mtf- of closed-lo
z.well Construction Permit#: �( FR.OM NG OR TI To DIAMETER TMCKNEss MnU IAL '
List all applicable will awutructian permits(t.e 111G County Smt4[rariancS etc) K• fL is
3.Well Use(check well use): ft ft. in.
EIndustniaMommerctal
ll: 17.SCREEN
FROM TO DIAMETER SLOTSIM THICKNESS MATERIAL
E)Mtt�cipal/Public
ating/Cooling Supply)�esidentiai Water Supply(single)
tL
ercial QlResideatial Water Supply(sfired) IS.GROUT
FROM TO MATERIAL FJ4MACEMENTMETnOD&AMOUNT
Mon-Water Supply Well: R A R ! s
Monitoring Recovery ft. F
Injection Well: ,
Aquifer Recharge ft. fL G
�GroundwaterRemediation !s
Aquifer Storage and Recovery ElSalinityBartier 19.SAND/GRAY>rLpACK rfa liwhle .
_ FROM TO MATERIAL EKPLACEf D
Aquifer Test MUM
tt. fL lti
Experimental Technology Subsidence Control ft. R
Geothermal(Closed Loop) [3Tracer 20.DMTX%IN LOG attach add rxonnl sheets if nirxnary) & uro
. Geothermal(HcatinatCoo' Retum) . Other(cs lain undcrlr2l Remarks) FROM To DEscalPnoN color,tmNrnss sviltroeke c m;a eta
t' fL S ".
4.Date Well(s)Completed: Well ID T 15 h' y6S
Sa.Well.Location: e. ft.
l'fnfi S LGft fL ft
FaciGry/Owner Name [ Facility ;(ifoppucable)
O �. ✓ ft. ft
" Z � ^lrot�.�.� s. —ft.
Physical Address,ChN and Zip ft fL
21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Mongis sufficient)
22.Certification:
• 32na _N Qo.(4Isa( w jo 2 22
6.Is(are)the weil(s) ..Permancot or OTenprary Sigatfure of Uillied W-eff Garactor Date
By signing this form,l hereby cerify that'the ivell(s)was dry canstrursed in accordance
I.Is this a repair to an eristing tire0: Yes or NO rvtih ISA NCAC 02C.0100 or 15A NCAC 02C.0100 Well Constriction Standards and that a
Phis is a r epab;fell out lmoxu hell rnnsrnrction infonnatlo explain the nature of the Copy ofihfs reca d has been prnv;r&d to the well owner.
mpafr under#21 rtvnarla section or on the bad,ofthisf
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 GW-1 is needed. Indicate TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
drilled_
SUBMLTTAL INSTRUCTIONS
9.Total well depth below land surface: (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multlpie wells list all depths ifdierew(example-3@200-and 2Q1005
r' construction to the following:
10.Static water level below top of casing: 7 Ijrvaterlevel is above cnsurg use 00 Division of Water Resources,Information Processing Unit,
'+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _Cn,) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Q fr/ above,also submit one copy of this form within 30 days of completion of well
0 -Muse,rotary,cable,direct push,,xc) 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(gpm) Method of test: II _ 24c.For Water SunDly-&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: Amoune dDi'J�.. completion of well construction to the county health department of the county
where constructed.
Form G V-1 North Carolina Department ofEavironmcuW Quality-Division of Water Resources
Revised 2-22 2016