GW1--03553_Well Construction - GW1_20230519

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WELL L®NSTR8UMON 1EC®M(GtW-It) al Use Only. — -
1.Well Contractor Information:
Cameron BaZn 14.WATER ZONES
WcltCanttactorNemo FROM TO DFSCWnON
y
451 B-A ZS 'L jS �,
6t. ft.
NC Well Contractor CertificatianNtmuber 15.OUTER CASING(for mtdti-cased wells OR LINER d a liable
Aqua Doll,Inc. FRont To MSIBR I)L TIDCKNESs MATE ML
CompanyName
16.INNER CASING OR TIIBING(geothermal closeddoo
2.Well Construction Permit#: FROM I TO I DIAMETER I TMCKNM ?ttATt]IfAL
L(st all applicable well conshuctionperuft ri e.UIC,Countp.State Yndanm etc) It. R in.
3.Well Use(checkwell use): it. It, in.
Water supply Well: 17.SCREEN
FROSI L TO DTAMMR Si.OTSTZE THICKNESS I MATERTAL
Agricultural DM micipallPublie fL it in.
Geothermal(Heating/C-ling Supply) Residential Water Supply(single) fL IL in.
1ndustrial/Commen:iai. Residential Water Supply(shared) 18.GROUT
11nigation. FROM TO MATERML MI WIACEMENPMEMOD&AMOUN-r
Non--Water Supply Welk O R' ?k Gl,l S
Monitoring - Recovery ft. &
Injection Well:
n.
Aquifer Recharge QGroundwaterRemedistion
Aquifer Storage and Recovery FROM
PACK NU licAL
�SalinityBarrier FROM 'tyi 6YAt'EItTAL Eat12ACEMtm-rMEsnoD
Aquifer Test 01StonnwaterDrainage fL fL
Experimental Technology [3Subsidence Control ft. ft
Geothermal(Closed Loop) EITracer 20.DRILLING LOG attach additional sheets irnee
FRon' To DESt'RWMNt color hardnem snwrael a rnta sffie.¢tcJ
EGeothemal(HeatinglCooGngRetum) —Oiher(exphuinumder#21Remarl.) 0 fL IL f
4.DateVel1(s)Completed; rl 1x1e111D# it. � &
5a.Well Location: fL is
HERS J2 a,(o G fL it .
Faciliryl0waerName Facility IDll(INpa-ble)
Physical Address,
(City,and Zip It. fL
��Irl r 21.REMARKS
{
County Pamel ldentificatioallo.(PIN)
5b.Latitude and longitude in degceedsoiauteslseconds or decimal degrees:
(ifwcll field,one Indlong is sufficient) 22.Certification:
3�-2N W S'fr�3
6.Is(are)the well(S)PIPernment or OTemporary Signature of certified well Contractor Date
By signing this form.I hereby certify that the tve$(s)xns(were)constructed in accordance
7.IS this a repair to an existing well: f]Yes or Min with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wag Construction Standards and that a
Ifthis.(s a repair,fill out knawn well construction inforatatr an-d-WI-ia the nature of the copy ofthis record has been provided to the waft owner.
repair under 921 rernarks section or on the back ofthisfor+n
23.Site diagram or additional well details.
8.For Geoprobe/lIPT 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.
dulled. SUBMTTI'AL INSTRUCTIONS
9.Total well depth bellow land surface: (L) 24a-For All Wells: Submit 9tis form within 30 days of completion of well
Formultrrple wells list all depths ffdifjemtt(emmple-3Qa 200'and 2@100)
C, construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
#'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699 1617
11.Borehole diameter. (in.) 24b.For Inlecfdon Wells: In addition to sending the form to the address in 24a
12.Well construction method: rp tip' above,also submit one copy of this form within 30 days of completion of well
lie.auger rotary cable,dir-P-b,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
139.'Yield(gpm) ( 7 Method of test: 5r 7/2:+7- 24ts For!]slater Supply&Injection Wells: in addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-i North Carolina Department of Environmental Quality-Division of WaterResotaces Revised 2-22-2016