GW1-2022-03861_Well Construction - GW1_20220331

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.'WATERZ0NEs
FROM TO DESCRIPTION
Well Contractor Name
4518-A pp fL $24
ft. %
NC Well Contractor Certification Number
.15:.OUTER:CASING-.for multi�at w*aS`ORLINER :a" 'Itcable
Aqua Drill, Inc. FROM To WAMETEx TmclavEss MATERIAL
O ft. C fl. in
Company Name
16:INNER CASING UR TUBING. eothermalcloSed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICIINESS afATFRrAr
List all applicable well construction permits(Le.UIC,County,State,variance,etc.) R• ft
3.Well Use(check well use): fL ft. in.
. REWater Supply Well: Fx M �o DIAMETER SLOT sum TKICxivEss MATERWL
Agricultural OMunicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. fL in.
Industrial/Commercial IoResidential Water Supply(shared) 18:GROUT
Irrigation FROM TO MATERIAL EMPLACRMEIVT METROD&AMOUNT
Non-Water Supply Well: O B' fL t
Monitoring D Recovery ft. ft.
Injection Well:
ft fL
Aquifer Recharge E3Groundwater Remediation
19.SAND/GRAVEL'YACK rf:a"licabie - -
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage R• ft.
Experimental Technology Subsidence Control & fL
Geothermal(Closed Loop) OTracer 20 DRILLING'LOG attach additional sheets ifn
Geothermal(Heating/Coolin Return) Other lain under#21 Remarks FROM To DESCRIPTION rnior hardness soiUroek ra eta
ft. G ft.
4.Date Well(s)Completed: LZ Well ID# ft' gels fL
k. ft.
5a.Well Location:
ft. fL
Facility/Owner Name Ir
II'' [ Facility ID#(if applicable) h' R
lanL furo R O�/ �� )/G�"WA�Ei ft. ft
IL y
Physical Address,City,and Zip �— k fL 1 20 )
�,�'� /L� 2L REMARKS.: t..
County Parcel Identification No.(PIN) ,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: a.,
(if well field,one latAong its sufficient) / 22.Certification:
le. f� ,7/ ?N 4O.(o1�D ) W /� y
6.Is(are)the well(s) Permanent or Temporary Signa ofCertiSed Wets ntractor Date
/ By signing this form,I hereby cer*that the well(s)was(were)constructed in accordance
7.IS this a repair to an existing well: �YCS orNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair fill out known well construction informatio and explain the nahrre of the copy of this record has been provided to the well owner.
' repair tinder#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: Q (' SUBMITTAL INSTRUCTIONS
Y 9.Total well depth below land surface: D Z J (ft.) 24a. For All Wells: Submit this form within 303days of completion of well
For multiple wells list all depths if&fferent(example-3Q200'and 2@100) construction to the following: yt.
10.Static water level below top of casing: -zoo O 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: (m•) 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: 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 Marl Service Center,Raleigh,NC 27699-1636
+13a.Yield(gpm) Or Method of test 24c.For Water SunDly&Iniection Wells: In addition to sendingpe form to
the address(es) above, also submit'one copy of this form within\%days of
13b.Disinfection type: Il Amount: completion of well construction to the county health department of itie county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016