GW1-2022-00147_Well Construction - GW1_20221219

Prin#.Fom1
WELL CONSTRUCTION RECORD(GW-1) For intemal Use Only: ---
L Well Contractor Information: i
Cameron Bazin
14:WATER'ZONES`.: ... "•.{;:'t'•' ...
WellContraclorName F;n-
15.OU-TER,CAEM�foimuld-i:asid-Wft):ORLDMRrif2fppbI DESCRIPTION
4618--A ft
rt i '
NC Well ContractorCertiScationNumber
abfe Aqua Drill,Inc. tATIatIAI
1 CoinpanyName
p fr. �o ft. i in.
U�tAL
n .-16.1NNER CASING'OR TUBING ebtherma!'closed]o _2.WellConstraCtionPermMk .3/OC FROM TO Tffic[avFss List aU oppGcable roll caeutrrrctianpermrls(ie UIC County,StateYmiaa 4 etc.) fr u.3.Well Use(check well use): fL ft.Water Supply Well: 17.SCREEN•:-•'CCjl — !•TtOM TO DIAMfiTER SLOTSI2E TAICKN
��.5 DMunicipallPublic & �
Geothermal(Heating/Ccoling Supply) residential Water Supply(single) ft ft iv.
kndustrial/Commercial Residential Water Supply(sbared)
._ T•1&GROU ..., . ..
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr. 2! ft t
Monitoring Recovery R
Injection Well:
rLAquifer Recharge oG roundwaterRemediation it
Aquifer Storage and Recovery (:''�salini Barrier 19 SAND/GRAVEL PACK tfa ticabte .
a—t' ty FROM. TO MATERIAL I EMPLACEMENTMETBOD
Aquifer Test oStoanwaterDrainage ft. ft.
Experimental Technology OSubsidence Control ft. ft 6
Geothermal(Closed Loop) OTtacer 2o:DR1LLINGL0G attach- additionalsheets'ifn'
Geothermal(Ticating/Cooling Return) s
Other(explain under Remarks) FROM To DESCRIPTION(color.namars.woivrocx
h,
4.Date Wells)Completed:_�S,VelI IDS ft It,
5a.Well Location: t1: ft.
��r a; 15t7ppr� ft.
Facility/Owner Name FacilitylM(ifeppGeable) % IL
ft
Physical Address,City,and Zip ft cc V�
fOtizA 2LREMARKS. t _ n
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r.i.. =`N/'•/l! -c
(ifwell field,one lat/long is sufficient)
�j 22.Certification:JS N $0. . o_
6.Is(are)the wells)t ermanent or EJTenrrary Signature afCeitified Well Contractor >hte
By s1p ling his fore,I hereby ccrt t/tat;dte rvell(s)was(urm)constricted in accordance
7.Is this a repair to an existing weD: Yes or No icidi 1SA NCAC 02C.0100 ar ISANCAC 02G.0200 WeU Consimcdon Standards and that a
IfOlisisarepair fipout latax�rnmllconsetrction'infonaati and explain the nauoeofthe cow ofthisrecard has beenprovidedto the iwJlmmer
mpwr wider M1 remarla section or an die back ofthisfo
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 i GW-1 is needed.Indicate TOTALNUMBER of wells construction details.You may also attach additional pages ifnmessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total rmultr ell depth below land surfacer at.) Y4a,For Ali Wells: Submit this fDnn within 30 Farwellipleavell&1alldepthrifdiffereat(eompla-3@200-and2@100� days Of completion of well
construction to the following:
10.Static water level below top of casing: 510 (ft) Division of Water Resources,Information Processing Unit;
Ijivaterlenel is aboWe casing use 1617 Matt Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. Cn,) 24b.For Iniection Wells: In additioa io 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
(Le,�e4 mtmy,cable,diractpcah;elc) Canstructioa#o the following.
FOR WATER SOPPLY WELIS ONLY: Division of Water Resources,Underground Injection Control Program,
j 1636 Mail Service Conter,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: D"ct "�l►- 24c.For Water Stmnly&Infection 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: Amount 6 7"'` • completion of well construction to the iced health depattment of the county
where constructed.
Form GW-I North Carolina Department ofEavimnmcutat Quality-Division of Water Resource
Revised 2-22 2016