GW1-2022-01902_Well Construction - GW1_20220210

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WELL CONSTRUCTION RECORD GW-I
For Internal Use Only:
I.Well Contractor Information:
14.WATER ZONES —
Cameron Bazin FROM TO DESCRIPTION
Well Contactor Name 1-40 jV ft. Z 63 ft. /cam 1
4518-A ft. ft. _
le
NC Well Contractor Certification Number 15.OUTER CASING for molt!eased welb O aCxEiRss a UMATERIAL
FROM TO UTAMi.TF.R
Aqua Drill, Inc. k. I� '° L
Cott�rarry Name 16.INNER CASING OR TUBING eotbern'al�INLSS MATERIAL
-737 FROM TO DIAMF-TER
2.Well Construction Permit#: b k, ft. In.
List all applicable well cons"chon permits rLe.WC,County,State, Variance,etc)
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER S1Or51l� THICKNESS MATERIAL
Agricultural IDMunicipal/Public ft, ft. in.
Getithetmal(Heating/Cooling Supply) 'Residential Water Supply(single) ft ft. Ia
IndustrialdCommercial Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL F.MPWCP.MENT METHOD AMOUNTlrfi ation
Non-Water Supply Well: k' k C�� ��
Monitoring Recovery k. ft. 1
Injection Well:
Aquifer Recharge E3Gmundwatrx Remediation 19.SAND/GRAVEL PACK if applicable) _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL — ZMPI•ACEMpNT METHOD
Aquifer Test [)Stormwater Drainage (t• tt. —
Experimental Technology E)Subsidcnce Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheelz[I necess
FROM TO DESCRIPTION ro ar tor,hd.sw wiUr k e, r do sire etc
Geothermal(Heating/CoolingRetum) Othcr(explain under#21 Remarks) R ft. Zn ft.
4.Date Well(s)Completed: Z7 Zl. Well ID# 'LD ft' G r��►,+ —
k. ft.
Sa.Well Location: —
/',
Facility/owner Name Facility IDA(if applicable) k• ft. —
Physical Address,City,and Zip
(/yI P
//� ��`1hG 21.REMARKS _
S
county Parcel Identification No.(PIN) —
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one long is suMctenr) 22.Certification:
M, 272 Yo N 80, 3 W
6.Ware)the well(00Permancnt or [3Temponry
Signature of Certified Well Contractor Dat
By signing this form.I hereby certify that the eved(s)was(were)constructed in accordance
7.1s thls n repair to an existing well: ['Yes orD No with 15A NCAC'02C.0100 or ISA NCAC 02C.0700 Well Construction Standards and that a
If this is a repair,fill out known well construction informatlo and expla/n the nature of the copy of this record hat been provided to the well owner.
repair wafer N21 remark section or on the back of this form, 23.Site diagram or additional well details:
9.For Geoprobe/DPT or Clowd-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 OW-1 is noeded. Indicate TOTAL NUMBER.of wells
construction details. You may dlso attacl additional pages if necessary.
drilled:__.. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface 2 6 S eft.) 24a. For All Wells: Submit this fonu within 30 days of completion of well
For multtple wells list ail depths if different(example-3W00'and 2@1007 construction to the following:
10.Static water level below top of casing: S (fL) Division of Water Resources,Information Processing Unit,
tf water level is above caring,use"i" / 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: & On.) 24b.For Injection Welt: in addition to sending the form to the address in 24a
l/ above,also submit one copy of this form within 30 days of completion of well
12.Well coney,cable, method, �� �`Y construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: �- a4 r 24c.For Water Supply&lniection NY&Lh: 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: 'c�1� Amount: �1j4 Z completion of well construction to the county health department of the county
when constructed.
FO^rt t W 1 North Carolina Department of Environtrenud Quality.Division of Water Resources Revised 2-22-2016