GW1-2022-05588_Well Construction - GW1_20220614

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WELL CONSTRUCTION RECORD(GW-i) For Internal Use Only:
L Well Contractor Information:
Cameron BaZil1 14.WATER ZONES'.
Well Contractor Name FROM TO DESCRIPTION
4518 A (00 ft. fL
R, f4
NC WcII Contractor Certification Number M OUTER.CASING formnl6 case@'wells OR L R(if a"le)
Aqua Drill, Inc. FRons To DIAMETER TDlctatFss nuTERIAI
Company Name C7 ft' O in.
4907� 16.INNER CASING OR TOEING(ebthermal closed-loon)
2.Well Construction Permit#: FROM I To I DIAMETER THICKNESS MATERIAL
List at!applicable nell construction permits(Le.WC,County,State,trarianee,eta) ft. f6 in.
3.Well Use(check well use): fL & in.
Water Supply Well: 17.SCREEN'.
A cultural PROM TO DIAMETER sLOTSIZE THICKNESS hUTERIAi
gn DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) It, fL ia.
PIndustrial/Commercial /D�Residential Water Supply(shared) IS GROUT
Irripation FROM TO MATERIAL EMPLACF,MENTMETHO➢&AMOUNT
Non-Water Supply Well: 0 ft. 2j,fL
Monitoring DRecovery ft. iL
Injection Well:
ft. fL
Aquifer Recbarge DGroundvrater Remediation
19.SAND/GRAVEL PACK rf a livable
Aquifer Storage and Recovery rDSalinityBarrier FROM TO MATERIAL rmPL&cEMENTMEriiOD
Aquifer Test t)StotmaaterDrainage ft. %
PExperimental Technology oSubsidence Control ft. fL
t3Geothermal(Closed Loop) QiTmcer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(HcatinJCooling Return) nOthcr(explain under#21 Remarks) +•ROM To DESCRIPTION(mror,hardness.snittrock a min svq arc
fL lip
4.Date Well(s)Completed:_e7� Well ID#
So.Well Location: ft.
AAGO'N 4",r«5 I ft. fL
Facility/
O
wne
rName Facility ID-1'(if applicable) ft. ft.
Physical Address,City,and Zip ft fL JI `
CI!fV 21.REOfARYS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
T1Gf Pr,�C r� ill
(fwell field one W/long is sufficient) 22,Certification:
32—?28 N SO.SO W f=n 2
6.Is(are)the well ' Permanent or OTemporary Siguature of Certified Well Contractor Da e
By signing this form,I hereby certify that the rvell(s)was(here)constructed in accordance
7.Is this a repair to an existing well: 0Yes nNo wish 15A ACAC 01C.0100 or 15A NCAC 02C.0100 Well Consinection Sim,dards and that a
Ijd+is is a repair;fi0 art/arox�r ueti roosMrctinnfon liars and explain the man+re ajtbe ropy ofthis record has been provided to the well owner.
repair under/!11 netaarlcr section or an tire back of this form+.
23.Site diagram or additional well details:
8.For GeoproberTPT 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled:
o SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 8S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3(@/200'and Z@100) construction to the following:
10.Static water level below top of casing: / (ft-) Division of Water Resources,Information Processing Unit,
If water level is above casing,use••r.. 1617 Mail Service Center,Raleigh,NC 276994617
Il.Borehole diameter: .4157 _(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
r®O� above,also submit one copy of this form within 30 days of completion of well
�r�w11 //(i.e_auger,rotary,cable,direct push,d construction to the following:
'
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SunDfv-&Iniection 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