GW1-2022-10757_Well Construction - GW1_20221209

" ` Print.Form•.......
WELL CONSTRUCTION RECORD tGW-1) For In Inal Use only:
1_Well Contractor information:
i
14:WATER'ZONES`.-
;Cameron Bazin ON TO DESCRIPI10111
*ell ConlractorName S ft, it. /�
4518-A & ft.
N'C Well Contractor Certification Number IS:OiTTERCAOSING"for m Di we .4 O MCKNESS
FROM
Aqua Drill,Inc. O ft. CO ft t"
company Name 16.INNER CASING'ORTOBING thermolCtt 10 t xFRtAl
I ["7217
' FROM TO DIAMErHa2.Well Const ruction Permit# ft. n In.
Listall applicable sell construction peenfienry�°�parlarue etc)
&
3.Well Use(check well use):
17.SCREEN
Water Supply Well: rROM To atAMSTSR sI orsrzs rincta�Ess afATcu,et. "
Agriculttn d ,DMunicipaltPublic fLft in.
_.Getthertnal(fieating/Cooring Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial olkesidential Water Supply(shared) S.GROUT
FROM TO MATEn1AL EMPId METHOD&AMOUNT
- Irri ation ft.
Non-Water Supply Well:
Monitoring Recovery ft S
Injection Well: fL
Aquifer Recharge EGmundwaterRemediadon 19.SANDi(.gA PACK rf cable .
SelinityBatrier FROM To MATERIAL EMPLACEMENTMEiHOD
Aquifer Storage and Recovery { ft, i
Aquifer Test �ioStormwaterDraimage
Subsidence Control ft'
Experimental Technology C -
Geothermal(Closed Loo) OTracer 20:DRILLING LOG attach additional sheets'if ne
p FROM TO DESCRIPTION color,Amdma.soivraek t ...Lnia sis,Ma)
Geothermal(Hc ItinglCoo Retnm) i Other(captain under x21 Remarks) ft. ft
ft.4.Date Well(s)Completed: ID Y Well
ft. ft.
Sa.Well Location: ft.
n/,t fit l.�oD� l/Id 1� ft !z
Facilitylo Narne FacilitylDO(ifapplicable)
ft. ft. D F
_ 30&.7 fL ft.
Physical Address.GSty,and Zip 21.REMARKS ivrrt 1 NPt^
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degreesiminutes(seconds or decimal degrees: 22.Certification:(f well field,one ladlong is sufficient)
,,,,� Signature::f a ifl J Well Contractor Date
6.Is(are)the we11(s) rmanent orTemporarY By Signing this form,I hereby certify that the lvell(s)was(woe)eonrtructed is accordance
7.IS this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consinta»on standards and that a
1f ids Is a npau•,fill out known w m ell nsintellon infonnadon and explain die nature of the cePl'olthis record has been pravidtdto the well mvner.
repair under#21 ranarks section or an the back of th6 form. 23.Site diagram or additional weIl details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe(DPT or©used-hoop 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
drilled: A SUBIVIITTAL INSTRUCTIONS
9.Total well depth below land surface:
2 7 (ft.) 24s.For All Wells: Submit this fors within 30 days of completion of well
For muln'ple wE&Dirt all depths ifdrrerent(erampie-3 20'and 2@1001 construction to the following.
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
fjrvater level is above etairtg,use'+••
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borebole diameter_ Cn) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rl'S � construction to the following:.
(ie.auger,rotary,cable,direct push eta)
Division of Water Resources,UDderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: G 1636 Mail Service Center,Raleigh,NC 27699-1636
0 /� w✓ 24c-For Water SnnDly-&Injection Wells: In addition to sending the form to
13a.Yield(gprn) Method of test the address(es) above, also submit one copy of this form 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 Department of Envitonmouta]Quality-Division of Water Resources
Revised 2 22 20%