GW1-2022-09951_Well Construction - GW1_20221031

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WELL CONSTRUCTION RECORD(G W 1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin 1a:wATERzoNEs'.. s: r
Well ContractorNarne FROM TO DESCRiP110N G'
4518-A 0ft. ft-
5 2S
ft. ft
NC Well Contraulor Certification Number
16.OUTERCASING'for multi cased hells OR LINER'rf a liCable'
Aqua Drill,Inc. FROM I TO I DIAMETER: THICKNESS MATERIAL
Company Name
O it. ft G. tn. VG
3 n 16.INNERCASINGORT[SBIlY ebthermulslosed-16s 1213
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2.Well Construction Permit#: V1 a FROM TO I DIAW ER; 1 THICtO1FSs I MAraR7A7
List a0 applicable xrlt construction parmile(ie.LTC CanaV.State I'ariumm etc.) ft. % in.
3.Well Use(check we11 use): fL R• in.
Water Supply Well: 17.SCREEN':';
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL,
Agricultural OMunicipal/Public ft, in.
Geothermal(Heating/Cooling Supply) i Residential Water Supply(single) ft ft
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPLACEMEMTMETHOD&AMOUNT
Non-Water Supply Well: ft /L Sr ft
Monitoring ORecovery M ft.
Injection Well:
Aquifer Recharge E3GmundwaterRemediation tt ft
Aquifer Storage and 19.SANDIGRAVELFA. rfa IIcable .
A
qRecovery OSalinityBarrier FROM TO MATERIAL I EMPLACENIENTMETHOD
Aquifer Test OStoaawaterDrainage ft. ft.
Experimental TmbnologyEDSubsidence Control ft. ft
Geothermal(Closed Loop) DTraeer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Coo' Return) i Othcr(axplain under 421 Remarks) FROM I TO DESCRIFRON(color.hardness,solvrock blizz,grain sac,etc.
t [t 0 ft
4.Date We (s)Completed: `� !/!i'Well IDT ft. 41 nROCA
Sa.Well Location: ft. tiII
:r --��- �,�i
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Faeitity/OwAcrNaarme FacilityIW(it'applicable) R ft.
ft ft
Physical Address.Ci ,and Zip T— ft ft
V*A U,
County Parcel Identification No.(PIN) EZLRMEMARMICS
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Wong is sufficient) 22.Certification:
36•oa?�i N 80 d,r���S( W �� �� t'/0 l q Z-
6.Is(are)the iveil(s) ,.Permanent or 13Temporary Signature o f Certified Well Contractor Date
By s/grdng this for,I hereby certify that the wells)was(owe)constructed in accordance
7.Is this a repair to an existing well: �Ycs or _ No with ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that
1Jthis is a repak fill out known well cotstncction fnJonna' a nd explain the natiur of the ropy ofthis retard has been provided to the well owner.
repair under 921 ronarks section or an the back of this
23.Site diagram or additional well details:
&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 TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
3 n� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@Jvo I Construction to the following:
10.Static water level below top of casing: VfV (ft) Division of Water Resources,Information Processing Unit,
I.rwaz never is above casing,use'+� 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: .�/` (m.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,ctc.) —7 construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) Method oftest 0�124a For Water Supply-&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fort 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 Deparhnent of Eavirotimental Quality-Division of Water Resources Revised 2-22-2016