GW1-2022-06863_Well Construction - GW1_20220719

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� �Frint Forrim .
WELL CONSTRUCTION RECORD G( .W-1) For Internal Use Only.
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1.Well Contractor Information:
Cameron Bazin 1 14.WATER ZONES f
FROM I TO DESCRIPTION
Well Contractor Name ft. ft
4518-A rt ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased.wens OR LINER Crf a ficable
Aqua Drill, Inc. FROM TO D ETER' THICKNESS MATERIAL
0 ft. Q 0 It
V i,
CompanyName 16.INNER CASING`ORTUBING closed-I'Dool
2.Well Construction Permit#: I/(t 5 Y FROM TO DIAMETER-, TdiCKNESS MATERIAL
List all applicable wv#1 construction penrdts(i.e.67C Coman Stag drarlatice etc) It. ft !n
ft iin.
3.Well Use(check well use): ft.
l Well: 17.SCREEN
Water Su
pp y FROM TO. DIAMETER !SLOT SIZE THICKNESS MATERIAL.
Agricultural utticipaUPublic fL ft.
Geotltelmal(Ileating/Cooling Supply) Residential Water Supply(single) ft ft, in.
lndustrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 23 ft ,a '
Monitoring- '... Recovery ft. ft.
Injection Well: M ft
Aquifer Recharge [3GroundwaterRemediation
19.sANDIGRAVELPACK rfa livable
Aquifer Storage and Recovery DSalinity Barrier FROM - TO 6ATERIAL EIIIPLACEMENT 1-MrHOD
Aquifer Test �Stormwater Drainage ft. ft.
Experimental Technology' (OSubsidence Control ft. ft
Geothermal(Closed Loop) ITracea 2o.DRILLING LOG(attach additional+sheets if nee )
DESCRII'T[ON Bator,hardness sotUrock
Geothermal(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO a rain ske eta)
,�/� � ft 70 ft
4.Date Well(s)Completed:-- Well ID# ?o ft' J S ft
ft. ft
5a.Well;Location:
FaciliVfOvmu Name Facility M#f(if applimble) fL
ft ft l
2022
Physical__Adrrrims%City,and tip ft t�.n C •�if
Yrl�d 21.REMAM'
I,
Wirv+»vtri iti�a i it 3C.C�7Wli 5/t��
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one latnongis sufficient) 22.Certification:
3E.12351 N go, yT$ 3 w
tIr
6.Is(are)the well(s)i` ermauent or [Temporary Signature of Certified Well Contractor Da
'By signing this form,I hereby certify tharthe well()nw(were)constructed in accordance
7.Is this a repair to an existing well: Yes or Wo with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 fYelf Construction Standards and that a
If this is a mpah;fill out known well coustruc-ors informatipeand explain the nature of the spy ofthis record has been provided to the well owner.
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.'Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessaty
drilled:
q¢ (' S17SM11TAL INSTRUCTIONS
9.Total well depth below land surface: / V- (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple:wdb&tall depths if different ti annple-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: %fl (fL) Division of Water Resource's,Information Processing Unit,
If ivater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: ¢n.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
�q above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: i""• 1/ construction to the following: 1
(La augc,rotary,cable,direct push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
> yy �
13a.Yield(gpm) Method of test: / 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 tolthe county health department of the county
where constructed_
Fom1GW-1 North Carolina Depattmentof Environmental Quality-Division ofWaterResources( Revised2-222016