GW1-2022-07250_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Satin la.WATCRZONES
FROM TO DESCWTIOM
Wc1lCapractorNamc ft.
4518-A
ft. ft �
NC Well ContractorCetti6cationNomber 15.OUTERCASING(for multicasedwells OItLINER tfa livable
Aqua Drill, Inc. FROM To DL R THICKNESS MATERIAL
O ft, I 49' ft 1 I,in:
CompauyName
—��[ 16.INNER'CASINGORTDBING" eothermalcllcutoo
2.Well Construction Permit#: Zr% MGM To DtA141ETER TaIcrINEss
✓' MATERIAL
List all applicable well construction permits r e UIC,Cotudy:State Variance.etc.) ft. ft It fa
3.Well Use(chedcwell use): it' tm
Water Supply Well: 17.SCREEN
FROaf -TO I DiAMETER I• SLOT SIZE I THICKtr'FSS MATERIAL
gricaItutal MunieipaVPablic ft 01- is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) & pL in, '
ustriaVCommelaial Residential Water Supply(shared) IS.GROUT
i _Irrigation FROM TO MATERIAL EMPLACEMENiMETHOD&AMOUNT
Non-Water Supply Well: ft
Monitoring EIRecovery % %
Injection Well:
Aquifer Recharge OGroundwaterRemediation
SAND/GR
Aquifer Storage and Recovery OSalinityBanier !ROMITOVELPACK R� Ate ypyACEMENTMETHOD
AquiferTest oStoffiwaterDrainage tt f
Experimental Technology Subsidence Control ft
r
Geothermal(Closed Loop) E3Traccr 20.DRILLINGLOG attach additional sheetsifn
gGeothermal(HeatingfCcoling Reftim) Other(explamunder#21Remarks) FROM TO DESCRIP[fON color,bordn-%somreck nsUe.etc
0 � awL
4.Date Weli(s)Completed:-�� Welt ID#
So.Well Location: ft. ft.
C ft. ft. i
Facility/Owneerm rNae rC 7 Facility lD#(ifapplicable) ft. it
kz1 sdr..�r' fL
Physical Address,City.and Zip r f .,
�t'i✓t ryVl �` 2L REMARKS
County Parcel Identificatioallo.(Pith I Pr"eGziytq!lout
D%VQ/8Q(3
5b.Latitude and longitude in degrees/minutes/smonds or decimal degrees:
(if wwcll field,one lWlong is sufficient) 22.Certification:
7 5i' •2O?T7 N g 0,48 YAD W
6.Is(am)the well Permanent or fOTemporary Si ofCettified Well Cmrhactor ! Date
By signing this farm,I hereby cent j&that the wel(s)xas(were)—traded in accordance
7.Is.this a repair to an existing well: I�`Yes or .- No with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction inform a and eiplatn the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the backof tlrisform.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may use the back of this page tolpmvide 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 ifnecessary.
drilled' r SUBMITTAL INSTRUCTIONS_
9.Total well depth below land surface: r 2-5 (X) 24a.For All Wells: Submit this•form within 30 days of completion of well
For multiple wells list all deptls ifdiffereut(esarnple.3@200'and 2Q100) construction to the following:
10.Static water level below to of casi V
p ng: (t1 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. CID.)) 246.For Iniection Wells: In addition to sending the form to the address is 24a
17.Well construction method: YIu above,also submit one copy of this form within 30 days of completion of well
/C? lTti construction to the following:
(i-auger,ratty,cable,direetpush,etc)
: Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELiS ONLY
1636 Mail Service enter,Raleigh,NC 27699-1636
13a.Yield(gpm) 27 Method of test: f 24c.For Water SnaDbv&Iniectiou 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
Farm GW-1 North Camlian Department ofEnvironmental Quality-Division of Water Resources Revised 2 22 2016
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