GW1-2022-04029_Well Construction - GW1_20220422

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only.
1.Well Contractor Information:
Cameron BaZirl 14.WATERZONET.
FRO5I TO DESCRH'TTON
Well ContmctorNamc 4S ft. S fL
4518-A fr. ft
NC Well ContractorCedificationNumber 15:OUTER:CASING'formuiti-criedivells'ORLINBRrfa liehble;•.':-
Aqua Drill, Inc. FILOM TO DiAMEfER 'IZ3ICKNESS MATEtvAL
Company Name 9 J c�1 46.LNrMCASING'URTQBING:( eothermnldosed-loo
2.Well Construction Permit#: `O 0 unty`0 Y / _ FROM ft. To f6 DIAMETER TiDct4VFss MATERIAL
all applicable well construction permits(i.e.UIC,Co ,State,lrariance,eta)
In.
3.Well Use(check well use): fL ft in. }�
Water Supply :17.SCREEN': `
PP Y Well: PROM I TO DIAMbTER SLOTSIZE THICKNESS I MATERIAL s
Agricultural I�Municipal/Public or ft. fL in.
:)Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R fL in.
�Industrial/Commercial Residential Water Supply(shared) 1S GROUT
Irrigation FROnnM TO MATERIAL EWLACEMENTMETHOD&AMOUNT
Non--Water Supply Well: ,,V ft. ft
Monitoring DRecovery D• D-
Injection W : - g•
Aquifer Recellharge DGroundwaterRemediation
.19.SAND/GRAVEL PACK(ifariplicalile .
Aquifer Storage and Recovery OSalinityBarrier FROM TO IvrnTERrAI EMPLACE(FrENTMEMOD
__ Aquifer Test 0Stormwater Drainage ft. TO
Experimental Technology E)Subsidence Control R• fL
RGeothcrmal
Geothermal(Closed Loop) OTmcer 2o.DRILLMG LOG attach additional sbeetsifnecessa(Heating/Cooling Return) Other(explain under#21 Remarks) ]FROM To I DESCRIPTION(color,hardness miltraelr rain sim ate)
L� p C> ft- 11 fL S Ate.
4.Date Wells)Completed: ` O ZZ. Well IM K D• pS fL
ft. R
5a.Well Location:
ft ft
�'{'Ci,r,�5ta� 'SokrSor
Facility/Owner Name Facility IM(ifapplicable) ft. ft 'c a•rs ,r ,. _y
Ar^ i� 1 G ft. fL
Physical Address,Cny,and tip A ft t4 APR 2 7
ZL REMARKS
County Parcel Identification No.(PIN) w .`..
5b.Latitude and longitude in degreesfminutes/seconds or decimal degrees:
(ifwell field,one lat/longis sufficient) 22.Certification:
3 4. 37a I1 N 0, 50'y W
6.Is(are)theweil(s)OPerSignature of CertiSed Well Contractor Date
manent or ®ITemporary
By signing this form,I hereby certh-that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or �No with ISA NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repab;fill outknonm cell construction infonnation and explain the ndiure ofthe copy ojehis record Iran been provided to the well owner.
repair under m21-rernarks 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 TOTALNUMB$R of wells construction details. You may also attach additional pages if necessary.
drilled: [ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Jam+ (it•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(example-3@2000•and 2QI005 construction to the following.
10.Static water level below top of casing: ?2 (L) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. Qn.) 24b.For Infection 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: �4CAfi� construction to the following:
(i.e.auger,rotary,rota cable,direct push,etc.)
ii Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Method of test: 24c.For Water Supply&Injection 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