GW1-2022-03839_Well Construction - GW1_20220331

44 F
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin lat.WATER`ZONES,
;[
FROM TO DESCRIPTION
Well Contractor Name �
it
5 ft
4518-A 7
ft. ft
NC Well Contractor Certification Number 15t.0UTERiCASING formulti cssed::w"ells URT LINER a'" bcable 5
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERL►L
ft. ft in.
Company Name
36 ��� 16.INNER C' ING OR TQB "othermahelose'd loo
2.Well Construction Permit#: FROM To AMETER TH[CKNFSs MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft• ft DI In.
3.Well Use(check well use): ft• rt. is
Water Supply Well: FROM TO DIAMETER SLOT SIM THICKNESS MATERIAL
Agricultural 3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) PtResidential Water SuPP1Y(she) ft ft. in. i
Industrial/Commercial Residential Water Supply(shared) iIL:GROUT
Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R• R
t Monitoring Recovery ft. it
Injection Well: % ft
Aquifer Recharge E3Groundwater Remediation
::19:,SAND/GRAVEL PACCifif:applicable):
Aquifer Storage and Recovery Salinity Barrier -FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage R• ft.
Experimental Technology OSubsidence Control ft &
Geothermal(Closed Loop) EITracer 20:DRILLINGLOG attach additional sbeeti fnieess
Geothermal(HeatinglCooling Return) Mother lain under#21 Remarks FROM TO DESCRIPTION color,hardness,solUroek type,grain size,etc
ft. O tt
5 Ana
4.Date Well(s)Completed: .249 2 Well ID# 30 ft. S ft.
ft. ft
Sa.Well Location:
ft. ft _
Facility/Owner Na a Facility ID#(if applicable) ft. ft
rb 1 / 'y ft. ft
MAR 202?
Physical Address,City,and Zip "` ft
00tAy 6 21.REMARKS.: t. ..
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
��• CO YD 2,* N 80• W
/it�li----- 2�
6.Is(are)the well(.)toPermanent or [1Temporary Signafirre of Certified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(wrre)constructed in accordance
- 7.Is this a repair to an existing well: Yes orNo with iSA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction!f,,-.,'', d explain the nature of the copy of this record has been provided to the well owner.
repair-under#21 remarks section or on the bath 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: 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@22000'and 2@100) construction to the following.
10.Static water level below top of casing: 7 (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:_, (n.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
O �l/ above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 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) t s Method of test: &Z�_'ce, Q_ 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
-7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: tb/o li completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016