GW1-2022-06058_Well Construction - GW1_20220629

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Cameron$aAn 14.WATER ZONES
FROM TO DESCRIPTION
Well ContractorName iZ
4518-A ft. tt•
NC Well Contractor CertificationNumber 15.OUTER CASING(for mntfi cased wells)OR LINER�f a licable
Aqua Drill,Inc. r•ROM fr. To ft. DllutitlTER in THICKNESS MATERIAL
Zv
CompanyName 16.INNERCASINGORT[JBING(geotheria closeddoo
FROM TO DIAMETER Te7CKNESS MATERiat.
mi
2.Well Construction Pert#: I�► ft in
List all applicable well construction permits(i.e UIC,Coemt},State.Variance,eta)
ft. ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TtiICKNFSS MATERIAL
Agricultural Municipal public ft. it. in.
:-)Geothermal(Ileating(Cooling Supply) residential Water Supply(single) ft fG in.
lndustrial/Commemial I Residential Water Supply(shared) 18.GROUT
7krigation FROM rTO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non ft.-Water Supply Well: o ft. 2 s
Monitoring [311ecovery fL R°
Injection Well: ft ft.
Aquifer Recharge DCnoundwaterRemediation 19.SAND/GRAVEL PACK rfa livable
Aquifer Storage and Recovery Salinity Barrier FROM To
MATERw EMPLACEMENT MET60D
Aquifer Test OStormwater Drainage R' R
Experimental Technology OSubsidence Control n R
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additiana9 sheets if necessar
FROM TO DESCRIPTION(mlor.hardn�ss,sotUnuk e, size.etn
Gcothe®al(Heating(Coormg Return) Other(explainunder#21 Remarks) (00 fL
4.Date Well(s)Completed: o Well1D# AV fL AS
� L ft
ft ft
Sa.Well Location:
ft. ft
Luyi✓�1 g, ft
Facility/owner l� Facility lD#(if applicable) _
r � l/l/Jr17.14�' � EL � �;�p'�"pr°'" •i't,_:'_�,.'d
Physical Address,City,and Zip 61�
21.REMARKS
County �� Parcel Identification No.(PIN)
5b.Latitude and longitude in degreeslrainutes/seconds or decimal deb ees: Y,,. ^�,�•. C:; .,i;j j, v r:
(tfwellfield,onelat/longissu0zcient) 22.Certification:
35.75'g8�' �, 8� iZv3l W
Signature of Certified Well Contractor Date
6.Is(are)the wel!(s) Permanent or Temporary
By signing this form,I hereby certh,that the,vell(s)Iv-(were)constructed in accordance
7.Is this a repair to an existing well: oYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out lazotvn well construction information d explain the nature of the copy ofthis record has beers provided to the xelf orwzer.
repair under#21 remarks section or on the.back ofthisform. 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. lndicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
drillech SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -as (fL) Z4a.For All Wells: Submit this form within 30 days of completion of well
Far nurlaple wells lisratl depths ifdifferent(example-3@200'and 2@1005 construction to the following:
10.Static water level below top of rasing: 7 t� ( ) Division of Water Resources,Information Processing Unit,
Ifrvater level is above casing.use"+" 1617 Matz 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: /�r !/ construction to the following:
(i.e.anger,rotary,cable,direct push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: c 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l 10 Method of test- 7 24c.For Water Supply&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 Water Resources Revised 2-22 2016