GW1-2022-06619_Well Construction - GW1_20220711

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only.
1.Well Contractor Information:
Cameron Bazin
14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4518-A
S & ft
ft. ft.
NC Well ConhactorCerlificationNomber 15.OUTER CASING(for maid-eased ivells)ORLiNER rfa licable
Aqua Drill,Inc. FROM To DLUNIETER THICKNESS MATERIAL.
I ft. 70 ft. in
CompanyName .
/�� C 16.INNER CASINGORTUBING eothermalclosedloo
2.Well Construction Permit#: ��/l/Y5a FROM TO DIAMETER , THICKNESS I MATERIAL
List aU applicable well construction permits#,a.UIC,Como,,State,Variance,eta) ft ft ih.
3.Well Use(checkwell use): ft. ft in.
Water Supply Well: 17.SCREEN
FRONT TO DIAMETER SLOT,SIZE THICKNESS MATERIAL
Agricultuml DMumcipal/Public ft ft in
—Geothermal(Heating(Cooling Supply) Ao
Residential Water Supply(single) ft. f. in,,
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT MET1iOD&AMOUNT
Non-Water Supply Well: ft G41 f
D Monitoring DReeovery ft. ft
Injection Well: & ft
Aquifer Recharge 0CrroundwaterRemediation
19.SAND/GRAVELTACK Ifa liable
Aquifer Storage and Recovery OSalinityBarrier FROM TO I MATERIAL I EMPLACEMENT METHOD
-Aquifer Test OStotmwaterDrainage ft %
Experimental Technology OSubsidence Control & fL
Gcothermal(ClosedLoop) DTracer 20.DRILLINGLOG attach additionalsheatsifneces'
Geothermal(Heating(COoling Retnm) MOther(explain under#21 Remarks) FROM - TO DESCRIPTION(color,hardness,soltirock type,grain size,etc
ft
4.Date WPJI(S)Completed: 611 Well ID# Cam' %
Sa.Well Location: DD ` & ft.
Qwwr1 h0 % ft.
Facility/Owner Name Faciility ID#(ifapplicable) R
(t ft.
Ale &o�.�ar.�oc.
Physical Address,City,and Zip �— ft ft jut
�l ts.lrry 21.REMAM
County Parcel Identification No.000 DO SEGTi0t�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
6.Is(are)the well(s ermanent or iOTemporary SignatureofCertified Well Contractor I Da
TBp signing this form,I hereby cJ),that the weII(s)was(µere)constructed in accordance
7.Is this a repair to an existing well: []Yes or MNo with ISANCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction informado and explain the nature ofthe copy ofthis record has been provided to the 6M aivaer.
repair under#21 remarks section or an 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
contraction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS I,
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9.Total well depth below land surface: �7 (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdiierett(ewmple-3Q200'and 2Qa 100) construction to the following:
10.Static water level below top of casing: �b (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. Cm•) 24b.For Injection Wells: In additiou 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: Y ZY�e f� construction to the following. I'
(Le.auger,rotary,cable,dimetpusb,etc) l i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) G Method of best 24c.For Water Suyyly&Iniectionl Wells: In addition to sending the form to
t�- the address(es) above, also submit one copy of thus form within 30 days of
136.Disinfection type: Ir 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
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