GW1--03533_Well Construction - GW1_20230519

Odril Form
WELL CONSTRUCI%ON RECORD L(M lj ForlutemalUseOnl3r - -
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM To DESCRIPTION I
fk
4518-A
tt ft.
NC Well Contractor CedificationNumber
15.OUTTRCASIPIG(for malti-s¢sedsv¢lls ORL1�R Ufa liceble
Aqua Drill,Inc. FROM To Dt4MEnR THlctcxM MATERIAL
CompanyWame 0 R i 5 7 iL in. }Mire:
16.INNERCASINGORTIIBING(eothermaldoseddeo
2.Well Construction Permit#: e,70 Z)0 FROM To DIAMETER THICS:N£S.S MATERIAL
List all applicable well construction pemdis f e.I/IG Cb-b-.Stata Variance eta) ft fil in.
3.Well Use(checkwell use): it• fL In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSiZE THICKNM MATERIAL
nAgricultural DMusicipal)Public ft. ft. in.
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single) M It. to
Industrial/Commercial DResidential Water Supply(shared)
Ill.GROUT
i -Irri lion FROM TO MA.TEMAL EDIPLACEMENT METHOD&Ah10UNr
Non-Water Supply Well: 0 fL 2_9 iL
Monitoring ORecovery ti. ft.
Injection Well: ft
Aquifer Recharge 00roundwaterRemediation 19.SANffi/GHAVELPACic,fa Ucable
Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL ENTLACEMM MEMOD
Aquifer Test OStormwater Drainageft. %
ExperimentalTechnology OSubsidence Control % R
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional 3beetsirnec
Geothermal FRO51 TO DESCRIP110N color,hudnea,soWnclt e, s►metc.
(IieatingJCooliagRetum) Other(e lainunder#21 Remarks)
4.Date Well(s)Completed:J1. S L�� Well mm (s o ft q2 It P OcA,
Sa.Well Location: fi: ft
ft. ft
Facility/QtvuerName Facility IDA(ifapplicable) it
% MAY' sa `
PhysicalAddress,City,andZip iL ft
(, 21.REMARKS r rtn i s', +�: it Nr`C:S `:�•. I Jrz
u�
Count FarcelIdentifitatioallo.(PIN)
5b.Latitude and longitude in degreesiminuteslseconds or decimal degrees:
(ifwcll field,one latnong is sufficient) 22.Certification:
6.Is(are)the weiloppermtument. or ElTempormy Signature ofCertified Well Contractor Date
By signing this form,I Iwreby cerio,that the tvel/(s)tws(were)cowlmded in accordance
7.Is this a repair to an existing well: (Dyes or DNo with ISR NCAC 02C.0100 or 15A NCAC 02C.0200 Wdl Construction Standardr and that a
Ifilds is a repair,fill out brown well construction infor natt and explain the nature ofrhe copy of this record has been provided to the well owner.
repair trader921 remarks section or on the back affIdTfornr_ 23.Site diagram or additional well details-
S.For Geoprobe/DPT or Closed-Leap Geothermal Wells having the same You may use the back:of this page to provide additional well site details or well
construction,only GW-1 is needed.Indicate TOTAL NUhMERofwells construction details.You may also attach additional pages ifnecessary.
drilled: SUBIt4MAL IN91RUCTI011TS
9.Total well depth below land surface: 1-Y2 S (R•) 242.For All Wells: Submit this form within 30 days of completion of well
For muldple tveUs list a9depths ifdE ferent(erample-3@�2j00-andl 1001 construction to the following:
10.Static water level below top of rasing: Y 0 UL) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. (in) 24b For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: <^b'tc-c)f above,also submit one copy of this form within 30 days of completion of well
(Le.auger.rotary,cable,dimetpusb,cto.) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLYr WELLS®NLY: 1636 Meg Service Center,Raleigh,NC 276991636
13s.Yield(gpm) I3 Method of test: QvrCl�� — 24c.For Water Supply&Injection Wells: In addition to sending the fora to
the address(es) above also submit one copy of this form within 30 days of
13b.Disinfection type: t Amount: �G�Z completion of well construction to the county health department of the county
where constructed.
Forum GW-I North Carolina Department of Eavimnmenml Quality-Division of WaterResources Revised 2 22 2016