GW1-2022-10756_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD(GW 1), For Internal Use Only:
i
1.Well Contractor Information:
Cameron BaZin 14.wATERZONES'.
FROM TO DESCRIPTION
Well ContractorNamc 24 ft, ft. `S
4518-A f• ft.
NC well Contractor Certification Number 15:OUTER CASING'for multi-cased-Wcl1s OR LMR if Iinale'
FROM TO DIAMETER TffiCIQ4ESS I MKCERIAL
Aqua Drill,Inc. O ft.
Company Name A A� .16.INNER CASING ORTUBING 5 ebtLermalciosed-16` ]FROM TO DIAMETER MECEeam MATERIAL
2.Well Construction Permit#: � ft. ft. io•
List all applicable xzU consv%mtfon permit$(Le U1C,Cauory,SM4 Variaum etc.J
ft, it in.
3.Well Use(check well use):
i7.SCREEN'::
Water Supply Well: FROM TO nIAMErER sI or slZ6 TtncKNEss rtATERIAI
Agricultural ©iMumcipal/Public ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) M tt la•
IndustriaVCommelcial /r Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERrAL EMpWCRMENTMETROD&AMOUN
fL [t
Non-Water Supply Well:
Monitoring DRecovery ft R
Injection Well: ft, ft
Aquifer Recharge DGroundwater-Remediation 19.SANDIGRAVELPA. s licable .
Aquifer Storage and Recovery OSalinityBaaier FROM TO MATERIAL. M"LACEMENTMECHOD
Aquifer Test 0StormwaterDrainanae ft ft.
Experimental Technology DSubsidence Control M th
Geothermal(Closed Loop) Tracer 20:DRILLING LOG attach additional sbeets if rue
FROM TO DESCRIPTION color,hardness.soilfinek e, rain SkS eta
Geothermal(Heatin/Cooling Retum) i Other(explain under n21 Remarks) ft too fL
4.Date Well is)Completed: `O Z 'wen ID', 6 ft. % rW.10
Lt. ft
5a.Well Location:
Facility/Owner Name Facility IDQ rf applicable)
Physical Address,City,and Tap :...., 1
2L REMARKS '
County Parcel Identification No-(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
C f well field,a=Wong is sufficient) 22.Certification:
3-5.2S&M N W
Signature ertifie eU Contractor Date
6.Is(are)the wens)r Permanent or Temporary
By signing this form,I hereby certyty that the rvell(s}was;(xerrJ constructed in accordance
7.Is this a repair to an casting Nyell: QYes of oNo wi0i 1SA NCAC 02C.o100 or 1SANCA4C 02C.0200 Well Construction Standards and that a
JfIft is a rVaIr,Jm out knoxa xell contraction informatl and explahi die nature of the
copy of this record has been provided to the well owner.
repair under 921 remarks section or on the back ofthisform. 23•Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed--Loop Geothermal Wells having the same construction details.You may also attach additional pages if necessary.
( construction,only 1 GW-1 is needed. Indicate TOTALNUMBER of wells
i drilled: /�C SUBNIITTAL INSTRUCTIONS
9.Total well depth below land surface: �f0! (ft-) 24a.For All Wells: Submit this form within 30 days of completion Of Well
j Formul6pte welts Est aD depths ifdii ferent(example-3@200 and 2@1001 construction to the following.
L
10.Static waterlevel below top of easing. So ( ) Division of Water Resources,Information Processing Unit,
Jfwater level is above casing.rue"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter__ _Cn•) 24b.For Iniection Wells: In addition to sending the farm to the address in 24a
/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: (O d -s 11s constructiouto the following
(Le.auger,rotary.cable,dire[push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: Q/t1 24a For Water SunpIv-&Iniection Wens: 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: Lim_ Amount: completion of well construction 6 the county health department of the county
where constructed_
Farm GW-I North Carolina Department of Environmental Quality-Division of Water Resavrces Revised 2-22-2016