GW1-2022-01908_Well Construction - GW1_20220210

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin lar.wATER'zoNEs
FROM TO DESCRIPTION
Well Contractor Name
4518-A too fL of fL 3o 6"
ft. ft.
NC Well Contractor Certification Number a'`hcable
15.OUTER CASING f6 mu11r-cased;iveDs ORE:INER
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
O ft. y y ft. 7-7
Company Name 46 INNER CASING'OR TUBING"e6thermat:el65ed400
2.Well Construction Permit#: 17 FROM To DIAMETER TTffcxivEss MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) R• ft i°•
3.Well Use(check well use): ft. I in.
17.SCREEN.:::.,-:..;::
Water Supply Well: FROM TO DIAMETER SLOT sisal rHlcluvEss IATERIAL
AgriculturalMunicipal/Public ft. ft. in.
Geothermal(Heating(Cooling Supply) residential Water Supply(single) fL ft, in
Industrial/Commercial DResidential Water Supply(shared) ;;18:GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Aquifer
ater Supply Well: 62 ft. 2 ft. t^6 + $ 14Z
oring i.:Recovery ft• ft
io
n Well: ft. ft.
er Recharge DGroundwater Remediation
Z.19 SAND/GRAVEL PACK d:a livable
er Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Test DStormwater Drainage ft. ft.
imental Technology OSubsidence Controlftermal(Closed Loop) ITracer -.20fDRIL$ING'LOG attachadditioniilrsbects if necessas
ermal(Heating/Cooling Return) Other lain under#21 Remarks) FROM r0 DESCRIPTION(color,kardnese soiUrock a to etc
fL TC, ft.
4.Date Well(s)Completed: 2 Z Well ID# 3 ft, ) U ft.
v
ft. ft.
5a.Well Location:
Facility/Owner Name Facility ID#(if applicable) ft. ft.
J o2— 1 1's1 i� G
�C 1ln e vX IA.VCFEB
ft. ft
Physical Address,City,and Z' ft. rt.
21.REMARKS.:
5 f/I izu
County Parcel Identification No.(PIN) 2029-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n
(if well field,one lat/long is sufficient) 22.Certification:
3G. 510$/ N �O� 04- �� W 2-
S ZZ
6.Is(are)the well(s) _Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ]Yes ornNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Weft Construction Standards and that a
If this is a repair,fill out known well construction informatiefi andexplain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section&on the back of this form. 23.Site diagram or additional well details:
8.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. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /YS 0L) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: V l7 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: fin•) 24b.For Iniection Wells- In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: &I 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 276994636
13a.Yield(gpm) �� Method of test: Z�G�Z V 24.For Water SuDD1v&Iniection Wells: 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: Amount: g completion of well construction to the county health department of the county
where constructed.
i
E
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources` Revised 2-22-2016