GW1-2023-02988_Well Construction - GW1_20230425

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Print Form 1
"WELL C 1'NSTUC'll'lON RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Cameron Bazin 14.WATER ZONES
Well Contractor FROM TO DESCRIPTION
ctotNamc
4518-A 03 5 ft* ft 6 G-p zj
R. ft.
NC Well Contractor CectififirationNmnber 15.OUTER CASING ffor multi-cased wells)OR LINER(if ap licable)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS MATERIAL
© � 7t) ft 6 in. �'r7ei
CompanyName
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Perlmitk 3 77 1 C�6 92 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(La OIC County State,Varianc4 etc) ' ft ft In.
3.Well Use(cheekwelt use): ft' it In. _
1 Well: 17.SCREEN
Water Su
pply y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply),Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shamed) le.GROUT
i krigation FROM TO MATERIAL EMPLACEMENT METHOD as AMOUNT
Non-Water Supply Well: 0 R GZ ft.
CA/Ir2Gl
Monitoring DRecovery ft. ft.
Injection Well:
Ft: ft:
quifer Recharge DoroundwaterRemediation
19.SAND/GRAVEL PACK(ifapplicable)
Aquifer Storage and Recovery Salinity Bonier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStomzwaterDrainage ft ft.
Experimental Technology InSubsidenee Control ft It.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets Knecresary)
Geothermal(Heating/Cooling Return) DOther(explainuader#21 Remarks) FROM TO DESCRIYfrox( >or,i,ardnes,satufnMctvpe EL R. grain sire.ate)4.Date Well(s)Completed: 17r1�Z/ WellLD# liC7 ft' 22- '' o lk
5a.Well Location: ft it . 1 ',.E C l Vft. ft. E D
5f�vein gr rGe.r
(?�rf
Facility/OwnerName Facility ID#(if applicable) ft. ft. A PR 2 5 2021
ft. ft
,
7ja LAA I/ I; - 1 e- Or e(Y�ez.. rt ft. il,�ium�,4 i;n1 F-ravassarfq Ur
Physical Address,Cit,amlZIp j� [+ ,'�'f�
• A[i1.OM✓ -21.REMARKS
County Parcel Identificatioallo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or deci®al degrees:
(if well Held,one latllong is sufficient) 22.Certification:
36. a36<e • N 84 3 .0g w L/--z r-/�? 1
6.Is(are)the well(s) Permanent or DTemporary Signature of Certified Well Contractor Date
By signing this foram,I hereby certlip that the well(s)tines(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with ISA NCACOZC.0100 or ISA NCAC 02C.0200 Wen Construction Standards and that a
If this is a repal,fail out/mown well construction informatp>fi anndd explain the nature of the copy of this record has been provided to the nail owner
repair under NI remarks section or on the back of thisfarn.
23.Site diagram or additional well details:
S.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-I is needed.Indicate TOTAL NUMBER of wells construction details.Yon may also attach additional pages ifnecessary.
• drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2z-5 (ft.) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdrfferent(example-3 a©200'and 2@100') construction to the following:
10.Static water level below top of casing: . (ft.) Division of Water Resources,Information Processing Unit
If water level is above casing use:" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: 6 (in.))) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (c y�1., above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) O construction to the foIIowirtg
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636 Mara Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpan) 7 5 Method of test: (t/' 17-- 24c.For Water Supply&Injection Wells: In addition to sending the fora to
,�[ 1I J / the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: / /7- Amount: /6;9,-2 - completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Qtmlily-Division of Water Resumes Revised 2-22-2016