GW1-2023-02480_Well Construction - GW1_20230404

WELL I Print Form '
JEJL L CONSTRUCTION RECORD(GW.�.l For Internal Use Only: - l —` -- -- -----
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
' Well Contractor Name FROM TO DESCRIPTION -
4518 A �9�� ft. / 6-A4-k
ft. it
NC Well Contractor CenificationNum er
15.OUTER CASING(for multi-cased wells)OR LINER(if op linable)
Aqua Drill,INC. FROM TO DIAMETER THICKNESS MI.iERIAL - •
CompanyName 0 ft. di ft. �' in. t°i"e--.
3 p 1 3 �.0 16.INNER CASINGOR TUBING(geothermal dosed-loop) -
2.Well Constl ttetion Permit#: O( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.tlic Cotur4t Stag Variance eta) ft. ft. tn.
3.Well Use(cheek well use): ft, ft. in. -
Water Supply Well: 17.SCREEN
FROnf TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft. in.
Industrial/Commercial Residential Water Supply(shared) IS.GROUT -• -
i Irrigation -FROM TO ,-. MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 2 5' fL 04,
• Monitoring ]Recovery ft. ft / -
Injection Well:
ft. ftAquiferRecha Recharge DGroundwaterRemediati on Aquifer Storage anal RecoveryS 19.SAND/GRAVELPACK(if applicable)
sty$�� FRon[ TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStomiwaterDrainage ft ft
Experimental Technology - OSubsidence Control ft. ft. •
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To D��ErSCRIPTION(color.badness,sontmck type,grain size.etc.)
4.DateWells)Completed: 2!2 1/- . ylrellID# 'jS It 70 5 ft tgS,r ks •
Sa Well Location: ft. ft. . r`"
S. ft. ' k.,.# I i y i��.L
FacilitylOwner Name Facility ID#(if applicable) ft
G/ 6-ti / (C rt. ft t_ w
tc��+, U'el�IGII
Physical Address,City,and riip ft ft. Iflioil if;.Si.;,i Cl 11 Pi'{l,,,:C9r,FF. 1..)f$
Al t( _told); 21.REMARKS LAN- cilia
•
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/ininutes/seconds or decimal degrees.
Orwell field,ono latllong is sufficient) 22.Certification:
31, 'leg a IC lv g62_ 9 7,0 e -
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f ?1i
6.Is(are)the well(s) ermanent. or OTemporary SigoahaeorCertified Well Contractor Date
8p signing this form,I hereby certtfy that the wells)tins(were)contracted in accordance
7.Is this a repair to an existing well: Dyes or J o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repel?:fill out;mown well construction in./armed avian the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the backofthisform.
23.Site diagram or additional well details:
Yon may use the back of this page to provide additional well site details or well
• 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed_Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary,
• drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ark (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For muluple wells list all depths ifdrffereat(example-3©200'and 2Qa 100' construction to the following: P
10.Static water level below top of casing: U 0 ft
If water level is above casing.use"+ ) Division of Water Resources,Information Processing Unit,
/ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a I
12.Well construction method: fOt above,also submit one copy of this•form within 30 days of completion of well
0.e.auger,rotary,table,tilectptah,etc.) ✓ construction to the following
FOR WATER SUPPLY WEI.I.S ONLY: Division of Water Resources,Underground Injection Control Program,
�(77 1636 Malt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: G7 br G�(�_ 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: H/f' Amount; t/65 0.--- completion of well construction to the!county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division ofWater Resources I Revised 2-22-2016
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