GW1-2022-04015_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information: r
Cameron BaZin 14.WATERZ0NES-. ..:.: ...
FROM TO DESCRIPTION
Well ContractorNamc 69 ft. Oft
4518-A fL
NC Well ContractorCertiScation Number m OUTER.CASING formal&rasi d Wc1Ls'OR INNER'da licatite':'- `:":
Aqua Drill, Inc. FROM I To DIAMETER THIcxivEss tATERIAL
In.
Company Name 1wn� :16.INNER'CASING'ORTUBJNa('ebthermal dosed-loon)
2.Well Construction Permit#: } FROM - TO DLIMETER Ft. THICKNESS KATRRIAL
ft in.
List all applicable well consUuction pernnils(i.e.UIC,County,State,[rariance,etc) •
3.Well Use(check well use): ft. ft ro.
Water Supply Well: :FROM
SCREE I T:-:
PP Y EROhi TO DIAMETER SLOTSILfi THICKNESS }IA7'RRIAI.
gricultural DMunicipaVPublic ft it is
0'Irripation
Geothermal(Heating/Cooling Supply) jaResidential Water Supply(single) fLIndustrial/Commercial Residential Water Supply(shared) isGROUT
FRONT TO MATERIAL EMPLACEMEWMEMOD&AMOUNT
Non-Water Supply Well: 19 ft. ft f
Monitoring DRecovery n- ft
Injection Well: g, ft
Aquifer Recharge oGroundwaterRcmediation
19.SAND/GRAVEL PACK tfa Itcabie
Aquifer Stooge and Recovery OSaliniry Barrier FROM To MATERIAL EMPr ACERIENT METHOD
_. Aquifer Test 0StormwaterDrainage R• ft
Experimental Technology DSubsidence Control ft it
Geothermal(Closed Loop) ®iTracer 20.DPJLLINGLUG attach additional sbeets if n-
Gcothermal(Heating/Cooling Return) ;. Other(explain under#21 Remarks) FROM TO DESCRIP110N(color hnndaess soillrack a cola sta ale.)
4.Date Well(s)Completed:
5a.Well Location: ft. it t-- r tc.
/t ft. ft.
I�L��� (� ft. ft. 7
FaciliityJ/O,vn/erName �I Facility lD#(ifapplicable)
r�Rii1 trir�if ft. ft ^�
Physical Address,City,and Zip ft ft
RIA 2LREMARICS
County Parcel Identification No-(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certifieation:�:;
W
6.Is(are)the well(s) ermanent or OTemporary signs of Certified We Contractor
By signing this forn,I hereby certify that the,vell(s)was(were)constructed in accordance
1.Is this a repair to an existing wall: ElYes or No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 well Construction Standards and that a
If this is a repau•,fll our knoum well construction inforn rtio and explain the nature of the copj,ofthis record has been provided to the,vell ovner
repair under 01 remarks section o•an the back of this form. 23.Site diagram or additional well details:
S.For GeoproberDPT 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: fl� —(ft-) 24s.For All Wells: Submit this form within 30 days of completion of well
For multiple mvells list all depths Tdifferent(example-3@2000'and 2@100D construction to the following:
10.Static water level below top of casing: 7t7 (ft) Division of Water Resources,information Processing Uni4
Ifwaterlevel is above casing,itse"+•' 1617 Mail Service Center,Raleigh,NC 27699 1617
11.Borehole diameter. (in.) 24b.For Injection 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(lWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I� Method of test: 24c.For Water Supply-&Injection Wells: In addition to sending the form to
per- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: l(s P completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016