GW1-2022-09952_Well Construction - GW1_20221031

i
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor information:
Cameron Bazin
14:WATERZONES*..
WellContractorNamo FROM TO DESCRIPIION
4518-A b ft. ft 2S
ft. R
NC Well Contractor Certification Number
15.ME Aqua ]rill,Inc. ROOU RCASNG'f01 TI _*11RO � a EvatiE' '
I
It IL in.
Company Name VC-
p -16.INNERCASINGORTDBING. ebthermalclosed-16
2.Well Construction Permit#: �13 83°t' FROM To DIAMETER THILTOVr_M MATERIAL
List aU applicable call eorLs&ucuon pamntr rl e.EffC County.State,State,Variance,etc.) ft. IL to.
3.Well Use(check well use): ft. ft
Water Supply Well: 17.SCREEN':
FROM TO DIAMETER SLOTS= THICKNESS
ai/Pbff MATERIAL
Agrientdltal Ohlunicipue ft. ft in.
Geothetma)(fieating/CooUng Supply) oResidential Water Supply(single) R ft in.
Industrial/Commercial 011esidential Water Supply(shared) 18.GROUT
I11'i ation EFRTO MATERIAL; EMPLACEMENT METROD&AMOUNT
Non-Water Supply Well: /�S' ,ft
Monitoring Recovery ft
Infection Well:
Aquifer Recharge [3GmundwaterRemediation ft
Aquifer Storage and Recovery RAVEL PACK-rf a tieable .
q 1 Very a-.YSailAity$8n7er TO MATERIAL. EMPLACEMENTMG[HOD
Aquifer Test [IStormwater Drainage It.
Experimental Technology Subsidence Control ftGeothermal(Closed Loop) ©iTracer NG LOG attach additional sbeets'dnecessaGeothermal(Aeating/Ceo' Retnm) : .Other( lain uadcr#21 Remarks) To DESCRIPTION(mler.Aardas.sellfrak raio sae,etet D R
4.Date Well(s)Completed: `0 ?/I Well mff ft. �L4 rtROCA
So.Well Location: ft• ft
51_.t)v ft ft.
Facility/OwncrrNa r— `•Y.GZJ Facility 11V(if applicable) R ft.
U�l9Y10Y ft. ft. C,�,. i � Grj..,
Physical Address,Cd,and Zip T— fL ft. r c.
yNA k 21.REMARKS
County Parcel ldentification No.(PIN) iPlii-' •a:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �j't•` -Jig"'?iJ :r
(f well
field,one latllong is sufficient) Qom, p 22.Certification. Q
6.Is(are)the wei](s) ..Permanent or DTemporary Signature ofCertiffed Well Contractor Date
By signing this fora;I hereby certify that the well(s)1vas(acre)constructed in accordance
7.Is this a repair to an existing well: DYes or _ No +6&15A NCAC 02C.0100 ar ISANCAC 02C.0200 W&Consintcrion Standards and char a
If thir is a repair,fill out k wun nzll cortrtntc6on info and a kda tire nawre of the ofthis record iws been provided to the ivell otvaer.
repatr under 921 rmnarks section ar on the back ofUrtr
lw 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:
p A� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ` ( ) 24a.For All Wells: Submit this farm within 30 days of completion of well
For mitlOple ivells list all depths ijdifereu(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: /6 (ft) Division of Water Resources,Information Processing UniS
Ijivater level is above eosin&use'+� 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- �/` (m.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (btl9A/ above,also submit one copy of this fort within 30 days of completion of well
(Le.anger,rotary,cablo,direct push,ctc.) _7 construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Infection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test 24c.For Water Supply-&Injection'Wells: In addition to sending the form to
]�. the address(es) above, also submit one copy of this form.within 30 days of
13N Disinfection type: I 1 Amount: completion of weil construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016