GW1-2022-07249_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: {
Cameron Bazin 1 14.WATER ZONES
FROM I TO I DESCRUMM I
WcllConuaetorName fL ft.
451 B-A ft. ft.
NCWellContractorCettificationNumber 15.OUTER CASING formultirasedwells'ORLMER da livable
Aqua Drill,Inc. rROM T n�AMLTER THICIINFSS MATERLML
O R n rn
CompanyName 16.INNER CASING ORTUBING(eothermal closed loo
2.Well Construction Permit#: � 4tr FROM ITo DIAMETER r TMGKN Zs I MATERIAL
List all applicable well co structlon permhis(t e.UIC,Cot60%State,Yad-4 eta) R R' In
3.Well Use(cheekwelluse):
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER SLOTSTZE THICKNESS MATERIAL
Agricultural DMunicipal/Public fL (L in.
Geothermal(Fleating(Cooling Supply) MResidential Water Supply(single) fL ft. in
Industrial/Commercial ACH Residential Water Supply(shared) 18.GROUT
lai ti0n FROM . TO MATERIAL EMPLACEM1ENTMETHOD&AMOUNT
Non-Water Supply Well: R 1- 'L
_Monitoring 13ltecovcry R. M
Injection Well: fL ft
:.]Aquifer Recharge oGroundwater Remediation
19.SAND/GRA'VELPACK(if a livable
Aquifer Storage and Recovery OSalinity Barrier FROM To ntATERrAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft
Experimental Technology OSubsidence Control ft. ft
Geothemal(Closed Loop) OTracer 20.DRIL LING LOG attach addittonal'sheets if necessary)
Geothermal EcatinglCooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION(color,Laranev;soWmek cats size etc
fL ft.
4.Date Well(s)Completed: Well ID# R' Q
& ft
5a.Well Location:
�iY�on /'tt, $A ft ft. 1F
Facility!//Owner j me c Facility 1D#(if applicable) ft Et ( i.
ft. IAUG 5
Physical Address,City,and Zip & ft. 4
— —�- 2L REMARKS ! t t
County Parcel IdentificationNo.(PIN)
i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)� 22.Certification:
�� w
'. Permanent or Temporary Si tumofCcrdfiedWellContractor ate
6.Ts(are)the well(s)
Sy signing lhi jorn,I hereby certify that Me wells)rrns(were)constructed in accordance
7.Is this a repair to an existing well: 2Yes o _ No with 15A NCAC 02C.0100 or 15A NCAC.02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construcff iirjorm on and explain the nature of the roPY ojthis record has been provided tothe -ell owner.
repair under#21 remark section or on the back of this a..
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 of wells construction details. You,may also attach additional pages if necesstuy.
drilled: SUBMITTAL INSTRUCTIONS I,
9.Total well depth below land surface: 2 /s ( ) 24a.For All Wells: Submit this!form within 30 days of completion of well
For muhiple wells list aR depths ifdlfjerent(example-3@200'and 2@100) construction to the following.
10.Static water level below top of casing: /0 (ft.) Division of Water Resource's,Information Processing Unit,
Ijwater level is above casing,use"+~ 1617Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
f��� above,also submit one copy of this form within 30 days of completion of well
12 Well constriction method: "�' construction to the following: I
(Le.auge,rotary,cable,dinxtposh,etc) I '
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
r /! 1
13a.Yield(gpm) Method of test: SIQ�ltr 24c.For Water Supply&Iniecti Ion'Wells: In addition to sending the form to
+f�� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Ie Amount:A/� completion of well construction to,the county health department of the county
where constructed. I
Form Gw-1 North Carolina Department of Environmental Quality-Division of Water Resources' Revised2-22-2016