GW1-2022-04873_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Intemat Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER`ZONES`.
FROM TO DESCRIPTION
to®
WellConttacrorName ft. TO
!
4518-A f
ft, ft
NC Well ContractorCertificatimtNumber 15.OUTER:CASING(roeTid casedlveUs OR-L`MR(ifn' TicrtiTe)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS MATERIAL
tfl.
CompanyName CASING'ORTURING ebthermalclosed-Ido .
2.Well Construction Permit#: To DIAMETER THICKNESS List all applicable well constructionpermits(r.e.WC,County,State,Varlaace•etc.) ft IP•3.Well Use(check well use): ft In.
Water Supply Well: 17.SCREEN'.
FROM TO DIAMETER IZE SLOT S THICKNESS MATERIAL
Agricultural DMunicipaUPublic fL ft. in.
_Geothermal(I1c ting/Cooting Supply) OResidential Water Supply(single) fL fL in
Industrial/Commercial DResidential Water Supply(shared) .18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R' S ft G�y
Monitoring DRecovery ft it.
Injection Well:
ft, ft
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVEL PACK tf a licable . '
Aquifer Storage and Recovery DSalinity Barrier FROM I To I MATERML i I EMPLACEMENT METHOD
Aquifer Test DStormwaterDrainage fL tt.
Experimental Technology ,Subsidence Control ft iL
Geothermal(Closed Loop) OTtacer 20.DRILLING LOG attach additional sheets if occessa
glCooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock a is s u etc
Geothermal(Heatin l
- � ft. �O ft
4.Date Well(s)Completed: �Y GC— Well IM b fr. its Tt
5a.Well Location:
C /r e` ft ft.
FacilitylOwnerrN("ame / �+' Facility
=((ifappliicable) ft. ft.
S Z.Z Z gf7G�/•• �✓/1 1 YW A,,o,o /Pik % ft.
Physical Address,City,and Zip ft. iL
Yell K f_:^ 2L REMARKS
County Parcel Identifieation`lo.(PIN) /tom
5b.Latitude and longitude in deb ees/minutes/seconds or decimal degrees; t <�
(ffwell field,one]at/long is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or OTemporary
oSignature of Certified Well Contractor
s r«
By signing this fora;I hereby certify that the tvell(s)was(were)eotutrui,drrrr aFcordance
7.Is this a repair to an existing well: QYes o No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Cotrstructian Stmiddr atul that a
ythis is a repair,Jill out known well cotrslnretion infonnati and explain the nantre of the copy ofthir record has been provided to the well owner.
repair under#21 reruarks section or on the back of this farm.
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: (ft) 24a.For Ali Wells: Submit this form within 30 days of completion of well
Formuldple wells fist all depths ifd(�erent(example-3@200'and2Qa 100) construction to the following:
10.Static water level below top of casing: 6 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
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 this form within 30 days of completion of well
12.Well construction method: r© t--o'n/ construction to the following:
(Le.auger,rotary,cable,direct pusk rteJ if
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) L 7 Method of test t r 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
r-^
13b.Disinfection type:�!Wig- 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 Water Resources Revised 2 22-2016