GW1-2023-02389_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD{GW 1) For 1lltemal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES i
Well Contractor Name FROM TO DESCRIPTION
4518-A
NCWeliConhactorCertifiptionNumbfT 15.OUTER CASIIVG(formniti-cesedwells)ORLINIIi ifa livable
Aqua Drill,Inc, r•ROM To DLAD E T111ClaQEss MATERIAL
fL i( It in.
ComparryName
16.INNERCASINGORTIIBING thermaldased-loo
2.Well Construction Permut#: . ' FROM TO DIAMETER TnICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,CormtJ;Stale,1radaum eta.) fG R: In
3.Well Use(checkweltuse): fL % 1n
Water Supply Well: 17.SCREEN
FROM TO 101AMErER SLOTSIZE THICKNESS MATERIAL
Ipicultutal DMunicipal/Public (t; In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL f. in,
lndustrial/Commercial 0Restdeuual Water Supply(shamed) 18.GROUT
i:11nigation FROM I TO MATERIAL EMPLACEMMUMErnOD&AMOUhz
FAquifer
er Supply Well: & z7 & ci
ing -Recovery & %
Well:
ft. fL
Recharge []GrotmdwaterRemediation 19.SANDIGllAVEi.PACK Gcable
Storage and Recovery DSCmiLy Barrier FRant TO MATERIAL. I EMPLACEMENT METHOD
Aquifer Test OStormwaterDrainage fL %
Experimetdal Technology OSubsidence,Control fL &
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG attach additionnl sheets irnec
Geothetmal(Heating(CoolingReturn) n0ther(explainunder#21Remarks) FROM To DESCRIPTION rnrer,hardness,snrUmek stm.etc.
0 ft. IG,) E s
r+
4.Date Weli(s)Completed: Well M# it• 7�� fl:
5a.Well Location: D' f:
Ile-
F=utyiownmi4a= ttFacdityW#(ifopplicable) it itAPR Jg 2021
� 2� V✓l ©� 1%�Ad�i.l^v�Y�G fL fr ;
Physical Address,City, Zip & fL
21.REMARKS
County ParcelIdenfificationNo.(PIN)
5b.Latitude and longttudein degreeslminuteslseconds or decimal degrees:
Gfw/c'll field,onee ladlonng is sufficient) [ 7 f 22.Certification:/
6.Is(are)the weD(s) ermanent or OTemporary
SignatmnofCertified ellConh=tor Date
By signing dill form.I hereby certh,that the wells)was ila—)constructed in accordance
7.Is this a repair to an existing well: [Yes or No with 15A NCAC 02C_0100 or 1SA NCAC 02C.0200 Well Construction Stendardr and that a
Jflhis is a repah;fill out Imorva well construction informadah and oplaln the nature of the copy offt record has beenprovidedto the xrll owner.
repair under#21 reawkssection oron the back-afthisfornt 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 ofwells construction details.You may also attach additional pages ifnecessary.
drffled SUBMYTTALINSTRUCTIONS
9 Total well depth below land surface: Z-1 00 24a.For All Welts: Submit this form witbm 30 days of completion of well
For multiple ivz&list all depths ifdigerent(aw nple-3@200'and 2Qa 100) construction to the following:
10.Static water level below top of casing. Ya (ft) Division of Water Resources,Information Processing Unit,
Ywater level is above casing,use"}" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: (in.) 24b.For Tniection Wells: In addition to sending the form to the address in 24a
12.WeD construction method: T above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direetpush,etc.) construction to the following:
Division of Water Rcsources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) y� Method of test: 7 t�(t 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
13b.Disinfection type: T` Amount: L �'-� completion of weu construction to the county health department of the county
where constructed.
Form GW-1 North CarolinaDepacrment of Environmental Quality-Division of Water Resources Revised 2 22 2016