GW1-2022-03098_Well Construction - GW1_20220307

r `_P�Int=Poem
Ji,CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZl11 .14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name fA fL I
451 B-A ft, M
NC Well Contractor Certification Number 15.0UTER:CASING(for multi-cased-wells ORLWR a licatile
Aqua Drill,Inc. FROM ft. TO iL D R ia. THIL'KNV MwrEmAL
Company Name n /� G Q� 16.INNERCASING'ORTUBING' ebthermaldose&loo
2.WeliConstructionPermit#: !r �� '"���_OCv • 3 FROM To nIArvfETER TEICKNESS MArEIZu+L
List all applicable well construction permits(i.e.WC,County,State,variance,etc.) ft• tL
in.
3.Well Use(check well use): ft. ft.
:17.SCREEN'-.:—
Water Supply Well: FROM I TO I DIAMETER I SLOTSIZ6 I THICHNFSS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Fleating/Cooling Supply)AResidential Water Supply(single) ft- IL in
Industrial/Commercial DResidential Water Supply(shared) 18 t•;ROUT
1rri lion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. /� ft.
Monitoring Recovery ft• ft-
Injection Well: ft. tL
Aquifer Recharge oGroundwater Remediation
..19.SAND/GRAVEI PACK da licabte .
Aquifer Storage and Recovery [Salinity Barrier FROM To MATERIAL EMPLACEMENTMETHOD
Aquifer Test ®IStoanwaterDrainage ft. ft.
Experimental Technology OSubsidence Control ft. it
Geothermal(Closed Loop) EITracer 20.DRILLING LOG attach additional sheets ifnecess
Geothermal(Heating/Coolin Return) r Othcr(explain under#21 Remarks) FROM TO DESCRIMON =tar,hardnrsa,sclUreck rain s' etc
tocp
4.Date Well(s)Completed:_!�Well IDff t ft. ft
ft. ft.
So.Well Location:
ft. %
Facility/Owner Name Facility ID#(ifappGLcabl�e) � R' ft
66 IV �.trGr%Id� 6Ut � k/&
Physical Address,City,and Zip I ft. ft. MAR ®7
LOA— 2LREMAPM
County (�(^ I'mccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwell field,one lat/long is sufficient) 22.Certification:
3( isf T1 N 29' C1YJt3S W 23 ?�
6.Is(are)the well(s)oPermanent or Temporary Signature ofCertified Well Contractor Date
By signing this form,I hereby certify that the well(s)was 6&vm)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with ISA NCAC 02C.ol oo or 15A NCAC 02C.0200 Well Consiniction Standards and that a
If tills is a repair,fill out known well*construction information and explain the nature of the copy afthi record has been provided to the well arvner.
repair under#21 remarks section or 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: 2-zs UP 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@100) construction to the following.
10.Static water level below top of casing: 70 (t.) Division of Water Resources,Information Processing Unit,
Ifwatei level is above casarg,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 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: `4 1� 1� 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)_ Z - Method of test; 24c.For Water Supply&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 completion of well construction;to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016
'i