GW1-2022-03840_Well Construction - GW1_20220331

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Prlri��Form ,
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin 1aiwATERZONEs
FROM TO I DESCRIPTION
Well Contractor Name ko @• 2 5 fL
4518-A ft. ft
NC Well Contractor Certification Number 15::OUTER:CASING:for multi cased wells`OR-LINER tf a licatile>.`'r:;r
Aqua Drill, Inc. FROM ITO DIAMETER I TWCKNESS I MATERIAL
ft. fL in.
Company Name n -
20 2 G,0 0� 16.INNER CASING OR TUBING "eethermal'cl ICMV
2.Well Construction Permit#: FROM TO DIAMETER THICI4VESS MCTQew
Gist all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft.
3.Well Use(check well use): ft ft. in.
[Industdal/Commercial
SuPPIY Well: `47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural 13Municipat'Public tt. it in.
" hermal(Heating(Cooling Supply) ?Residential
esidential Water Supply(single) fL fL in
Water Supply(shared) G�Y 18.GROUT
7.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft 'ft f
Monitoring ORecovery ft• ft
Injection Well: & fL
Aquifer Recharge OGroundwater Remediation
..19.SAND/GRAVEL.PACK if:applicable).
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENTMisTaoD
Aquifer Test [3Stonnwater Drainage rt• ft.
Experimental Technology DSubsidence Control it ft
-- Geothermal(Closed Loop) OTracer 2o.DRILLING LOG attacli:addifienal sbeets if necessary)
FROM TO DESCRIPTION color,hardness,solltrock e rain she,etc.
Geothermal(FIeatin Cooling Return) Other(e lain tinder#21 Remarks) ft `.f &
4.Date Well(s)Completed: s Z2- Well ID# ! ft G ZS fL
ft It.
5a.Well Location:
Glad S Aye; ft ft
Facility ID# ifs applicable) rt• ft ,
Facility/Own F bry ( PP �r
1 ft f6
fL fL 1 zoz,,
Physical Address,City,and Zip
2L REMARKS '
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:
3 G. 10Z'q 2 N SO [908 W le�-���
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor I Date
By signing this form.I hereby certify that the well(s)was(were)constructed in accordance
1.Is this a repair to an existing well: ]Yes or o with 15A NCAC 01C.0100 ar MA NCAC OX.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information 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 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-1 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: 62. (ft-) 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 2Qa 100) construction to the following:
10.Static water level below top of casing: So (fL) Division of Water Resources,Information Processing Unit,
If iwuer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: Cn•) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of tbis form within 30 days of completion of well
12.Well construction method: f Y construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Resources,Uaderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) i/2 Method of test:OGCAC-V- 24c.For Water SuoDly&Injectitia 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 ithe county health department of the county
where constructed.
i
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016
01