GW1-2022-06621_Well Construction - GW1_20220711

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wen Contractor Information:
Cameron Bazin 14.WATERZONES
Wc1lConuaMorName FROM TO DESCRIPTSONI
4518-A 2S tit. !s
ft. ft �
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased wells OR LINER d a licabl%
Aqua Drill,Inc. FROM zo D T>�cxNESS MATERIAL
CcarnanyName
C,(� 16.INNER C%SING OR TUBING thermal elosed-loo
� )Rout zo nuntczElt rlHcxivEss mrArEtuAL
2.Well Construction Permit#: o r
List all applicable well construction pemiiis ilze_WC,Cotmo}:State,rariance etc) % % bl'
3.Well Use(check well use): ft. ft j is
17.SCREEN
Water Supply Well:
FROM TO DIAMETER 'SLOT SIZE TRiCKNESS MATERIAL
Agricultural MunicipaUPublic ft ft. in.
. Geothermal(Heating(Cooling Supply) 6i Residential Water Supply(single) ft. ft. in,
IndusUWCommercial [31tesidential Water Supply(shared)
18..GROtJT I '
i.1krigation FROM TO MATERIAL ENIPLACEMNTNIETROD&AMOUNT
Non.-Water Supply Well: ft. X ft.
Monitoring Recovery ft. ft. r i
Injection Well:
:)Aquifer Rech ft
urge �GronndwaterRemediation
19.SAND/GRAVEL PACKff applicable)
AQufer Storage and Recovery SalinityBarrier
FROai TO 1 MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fL
Experimental Technology L tit.
�_i'Subsidence Control fc
Geothermal(Closed Loop) 1211racer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooliag Retain) Other(explain under#21 Remarks) FROM TO DESCRIPTION velar,hardness,sol0iodc a rain stze etc
4.Date Well(s)Completed: 22 Well>D# ft• iyY(' ft: Pr.Q/k,
5a.Well Location: ft: fL
�'l�l/fpn 11an1�S fL ft. i
Facility/ Nam. FacilityJD#(ifapplicable) fL f
pOf�� r�r,yt� ft. ft. him
Pbysical llddress,City,A Zip ft. ft.
SC 2L REMARKS
County Parcel IdentificationNo.(PIN)
Dt ti0t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwe0 field,one lat/long insufficient) 22.Certification: r M SAI IN RUBS i UNIT
� GoG 6' W
�g z�
6.Is(are)the well( Permanent or f�Temporary
Signature of Certified Well Contractor Date
�So- By signing this forum I hereby cer ifp that the ivell(s)u=(were)constructed in accordance
7.Is this a repair to an existing well: I[�Yes or _ No with 15A NCACO2C.0100 or 15A NCAC 02C.0200 Well Construction Standards and Mat a
1f this is repair,fill out known well construction inform and explain the nature of the Copy ofthis record has beenprovided to the well owner.
repair under#21 rernarla section or on the back of thisf rm. f
23.Site diagram or additional w4details:
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 ofwells conshuction details. You nay also attach additional pages if necessary,
hued' L v SUBrV TTAL INSTRUCTIONS
9.Total well depth below land surface: 7 1 (fL) 24a.For All Wells: Submit this�foim within 30 days of completion of well
For multiple wells list all depths ifdifferear(example-3(a)200'and 2Q100) construction to the following:
10.Static water level below top of casing: 5'0 (ft) Division of Water Resources,Information Processing Unit,
.If water level is above casing,rise+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection 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: Ck rot cl
0-c.auge,rotary,cable,directpush,etc.) construction to the following.
I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: (' 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm)�Method of test: 7 24c.For Water Sna��&Iniecti m Wells: In addition to sending the form to
/ the address(es) above, also submit doe 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