GW1-2022-05959_Well Construction - GW1_20220615

WELL CONSTRUCTION RECORD(GW 1) For Int'emal Use Only:
1.Well Contractor information:
Cameron BBZII.1 14.WATER'ZONES`.
Well ContractorName FROM TO DEXRIFTTON
4518-A 170 ft & 20
ft ft
NC Well Contractor Certification Number
15:OUTER..CASING'formulti-casetiwclls�ORL'IIdER'tfa licatile- '
Aqua Drill, Inc. FROM To DIAMLTER TFUctavEss IVIATSRw
ft. I
1 Q R 44 in.
CompanyName
2Zo��OO � 36.INNERCASIIQG'ORTUBIIVG('ebthermalclosed-ia . .
2.Well Construction Permit'#: FROM I To DIAMEM TMCKNEsS MATERIAL
�y d !�
List all applicable toell construction permits r.e.L>7�County.State,variance,etc) ft ft In.
3.Well Use(check well use): ft ft.
Water Supply Well: 17.SCREEN',
FROM TO DIAMETER SLOT SIZES THICKNESS MATERIAL
Agricultural iD� Municipamblic ft. ft.
Geothermal(Heating(Cooling Supply) residential Water Supply(single) ft ft in.
--Industrial/Commercial Residential Water Supply(shared) 1&GROUT
Ir'ri ation FROM TO MATERIAL EUPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: R :? fL
�.
Monitoring ORecovery ft. ft
Injection Well:
A ifer.Rech e ft ft
tpr argGmundwaterRemediation
19.SAND/GRAVEL I'ACSC da Icable .
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
Aquifer Test DStormwaterDrainage tt. it
:]Experimental Technology OSubsidence Control ft. ft
:)Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if nccessa
` Geothermal(Heatin(Cooling Retina) FDOther(explain under 921 Remarks) FRON' TO DESCRIPTION color,hardness,soigmck ., -inshe etc)
�+ ft. '* ft
4.Date Well(s)Completed: .7 !92 Well ID 20 ft. 15 ft.
5a.Well Location: /G ft. D•
(Q Y A>n 114�� ft. ft
Facility/Own�Name Facility IDQ(if applicable) ft, It — =A�mem Qa q
Physi L Addtcss,City,and Tap ft. ft
acfb Il/im 2LREMARKS
County Parcel Identification No.(PIN) ���,�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Certrfrcation:
(wwell field,one latfiong is sufficient) 22. ' "'Z'•=y'+' t Iv °rY 1:,i
39 y3z 7( iirr��rrrrt��_ N 79•• 8918
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Well Contractor Dat
���}yyttt
By signing this form,f hereby certify that the ivell(s)ivas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or MNo rvllb I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knaxat cell consintetion infonnatIV6nid explain the nalum ofthe IVY ofthis record has been provided to the well owner-
repair-under 021 remarla section or an tyre back ofthisform
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells ha%zng 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 All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@20 Qa0'and2 1005 construction to the following:
/
10.Static water level below top of casing: /0 (ft) Division of Water Resources,Information Processing tint,
Ifivater level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699 1617
11.Borehole diameter: (n.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 106 1r r), above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Q Method of test� A f— 24c.For Water Supply-&Infection 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 bealth department of the county
where constructed.
Form GW-I North Carolina Department ofFirvironmental Quality-Division.of Water Resources Revised 2-22 2016