GW1-2022-03044_Well Construction - GW1_20220228

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For Intema Use Only:
wEI L CONSTRUCTION RECORD(GW-11 =
!'Well Contractor lufor'rorttloa: 14.WATZR zor�s paaL1U►ROM_.
TO
Cameron Bazin rt. —
H'c��Contractor Nam IL R. at�61e
t5� CAS
� weal
N OR L11VLR t
� l � p `)-7} r'nICICN[a5 MATaRrAt.
CW' 1l Contrnmor Certification Number ►sOtut TO�G o let rt.
Aqua Drill, Inc, I� fpR CASING ORTLM -and Mao? atATtOUAL
TTrrcictrna
CompanyNeme rL TO h.FROM IL
2'Well Conatructlon Penult#' r� '` '" etc) Is.
L•rt all appticable-ell mnrrnrction permits(Le.U1C,County.Stale,Varlanee, it. ft.
3,Well DlAataT TiiiCKNPBB MATpt1AL
Use(check well uae): 17.SCAERN s,;ar Sr7B
TO
Water SuPPIy Well: FROM ft ft. la
Agricultural �MunicipaMblic
1. ft
J _
CreOthermal(Heating/Cooling supply) Gal Water Supply(single) ft 6MPLACL�fEKr Me w.D —AMOUNT
IndustriaUCommemial Residential Water Supply(shared) 18.GROUT MA 1�►L —
FROM TO
Irri ation
Non-Water Supply Well: J ft
ft.
tvlonit w Recovery ft- —
lnjection Well: ft-
Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVEL PACK If a tlpble_ EMPLACatMP21T MEM013
FROM —
Aquifer Storage and Recovery Barrier Salinity Baet TO ft. MATFRIAL
Aquifer Test ft.
[3Stormwater Drainage
Experimental Technology oSubsidencc Control
Geothermat(Closed Loop) FR Tracer DRILLING LOG attachDdditloualto ptor Ya lo�Yrack etc.FROM 70
Geothermal(Heatin Coolie//Return) Other lain under#21 Remarks ft. ff. LL
4.Date W ft' 5e5 fb
Welt(s)Completed: I� / Well ID# ft.
58-Well Location: ft. —
ft. ft.
l IGV fog^ A ft ft. —
Facihty/ Name Facility lD#(if applicable) —
Physical Address ,and Zip ft. ft
21.REMARKS —
County ![ Parcel Identification No.(PIN) —
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if�well field,one 3 la/longi's sufficient) I 22.Certification:f�241 N o. fQ% W —��_ _
S afore of Cart ell Contractor
6-Is(are)the weli(s) ermanent or [ Temponry
t� tfi )ate
By stgning this form,I hereby certify that the well(s)xns(were)constructed in accordance
7 is this a repink to an existing well: QYes or No with 15A NCAC 02C.0100 or 15A NCAC 112C.0200 Well Construction Standards and that a
ljthis is a repab,ft1!out btowrt we/l construction injormatio and explain the nature of the copy of this record has been provided to the wt,ll owner.
repair under#21 sear+:setaon or on the back of this form. 23.Site diagram or additional well details:
Lon Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop P construction details. You may also attach additional pages if necessary.
Construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled. SUBMITTAL INSTRUCTIONS
below land surface: (ft) 24a. For All Wells: Submit this ;:orm within 30 days of completion of we
9.Total WCU depthconstruction to the following:
For rnuMple'"ells lot all depths ifA ferent(example-it�200 and I®l00�
water level below top Of��' fl (ft) Division of Water Resourcel,Information Processing Unit,
f Static 1617 Mail Service Centxr,Raleigh,NC 27699-1617
lj water lave/is above casin&use„+-
(hL) 24b.FQr Iniection W , In addition to sending the form to the address in 24a r
11,Borehole diameter'---tt��/ above,also submit one co of thin f 3tTn within 30 da
construction to the following: of�tnPletion of well
12.Well/opstruct>an method:do)
(i auger,rotary,csb►c,direr P Division of Water Resources,t ncierground Injection Control Program,
FOR WATER SUPPLY
WELLS ONLY: 1636 Mail Service G;nt:er,Raleigh,NC 27699-1636
Method of test: 24c,F4_r Water Suonl� 8 Inl h
13a.yield(gpm) '`jT' the addresses) above, also submit one
((�� l� completion Of well construction �� ells. In addition to candle
Amount: b Z copy of this fo B the form to
die coon within 30 days of
136.Dlsm
fectiom type: where constructed. county health deparpnent of the county
North Carolina Department of Environmental Quality-Division of W afar
Form GW"1 �xources
R0t''sed 2-22-2016