GW1-2023-02990_Well Construction - GW1_20230425

Print Farm 1
CONSTRUCI'ThLN TRECIrRD(GW-11) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZOPiES
FROM TO DESCRIPTION
Well CorrtractorNamc g ft. g
'"
4518-A l
ft: ft.
NC Well Contractor CertificationNum6er 15.Ott-fiRCASING(formold-cased wells)OR LINER(If apptimbre)
Aqua Drill,Inc. MOM TO DIAMETER THICKNESS ) MATERIAL
CompanyName
t ft. 'g ft. G in. c�pG'�
78, a 8 S 16.INNER CASING OR TUBING(geothermal etosed loop)
2.Well Construction fl'erm3r#�: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UiC Co mnt Stag Variance,etc) ft. ft. In.
3.Well Use(check well use): ft' in.
Water Supply Well: 17.SCRUM'FROM 7'® DIAMETER SLOT-SIZETtirCiCN[SS MATERIAL
Agricultural DMunicipalPublic ft.; ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft: It in.
Industrial/Commercial Residential Water Supply(shared) is.GROUA•
i Irrigation FROM TO •- MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. �lyi ft 641 l•
Monitoring Recovery ft. ft. `
Injection Well: ft. ft.
ft.
Aquifer Recharge DGroundwaterRemediation
19.SAPID/GRAVEI.PACK(if applicable)
quifer Storage and Recovery Salinity Ranier FROM , TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ElSturmwaterDrainage ft. ft.
Experimental Technology DISubsidenee Control ft It
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional"sheets if necessary)
Geothermal(Heating/Cooling Return) f Other(explain under#21 Remarks) -FROM TO DFSCRIP[rON(�lnr,h¢rdness,sciVrnetcLype Rraiastze etc.)
Q fr 10 fL �5a�1
4.Date Well Is)Completed: ��/D.� IID#Well 't7 R' � -,
u ft l--e?U'k.
5a.Well Location: /� ®E d `°-'
• v�� (Lay reeele/ ft. ft. 8 CI.,)
Facility/OwnerName Facility lDIl(if applicable) ft. ft APR h pp 2^23
z�
ft. ft. �P
j�ctr ,l'�YN or p;-��. G/� _ ft. fr. OniamPialion Pracaliskis ttrlr
Physical Address,City,and Zip
A69 t1) 21.REMARKS
County Parcel Identignatiaa No.(PIN)
Si).Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wen field,one lat/lotg is sufficient) 22.Certification:
36. t27 -' Pi g/i 2_1'2ot w
6.Is(are)the well(s) ermanent or E3Temporary Sigoatutcof Certified Weil Contractor Date
By signing this form,I hereby certify that the well(s)cur(were)constructed in accordance
7.Is this a repair to an existing well: IDYes of �No with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
'this is a repair,fill out known well construction informer: andand explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or on the back of thisfarm-
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-1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
wed' SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface: ;25 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200•and 2@I00) construction to the following:
10.Static water level below top of casing: cC2 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above easing,use"+" A 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: (.10 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Weft construction method: ��j}T'�f'?� above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) `/ construction to the following_
, Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 Method of test: 7r 7/17 24t:.For Water Supply&Injection Wells: In addition to sending the form to
1 / the address(es) above, also submit one copy of this loan within 30 days of
13b.Disinfection type: �✓rirf Amount 1 72-- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of WaterResoseces Revised 2 22 2016