GW1-2022-07565_Well Construction - GW1_20220815

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only-
1.Well Contractor Information:
Cameron Ba2in 14.WATER'ZONES`.
Well Contractor Name FROM TO DESCRIPTION
4518-A G ft. It ZIP
ft. ft
NC WellContractor Certification Number 15.OUTER CASING"for muifi-ms'eR welts OR I IIVER tf a' lieatile •'
Aqua Drill, Inc. FROM TO DIArdMW TffiCr.T1ESS MATERIAL
ft. 65 ft in.
Company Name
�//'' 16.INNER CASING
DR TUBING eothermal closed-ldo
2.Well Construction Permit#- C7(J(O I(7 FROM TO DIAVVIETEFt I THICKNESS F MATERIAL
List all applicable well construction permits(i e.UIG County,State variance etc.) it ft i°•
3.Well Use(check well use): ft. ft. i°•
Water Supply Well: 17.SCREEN
FROM TO DIAMETER --SLOT-SUM I TIUCKNESS MATERIAL,
Agricultural ,�MuniLtipaUPublic ft. ft in.
_ Geothermal(Headug(Cooling Supply) (Residential Water Supply(single) M IL to
IndustrialfCommercial Residential Water Supply(shared) IS.GROUT
LTi ation FROM TO MATERIAL! EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. !t ry; rQ
Monitoring Recovery fL ft. ' 3
Injection Well: @. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACR(It applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL' EMPLACEMENT METHOD
Aquifer Test iOStonowater Drainage ft. ft
Experimental Technology IQ_ (Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sbeets'if necessary)
Geothermal(Heating(Cooling Return) i Other(explain under#21 Remarks) FROM TO DESCRIMON color harder.,wiltraelr a gin sbm,etc
ft 0 ft
4.Date Well(s)Completed: Well W# It ft.
5a.Well Location: ft' ft
fL ft.
Facility/O//w��n er, ame tttfff � \F�(aci�li y W#(if applicable) ft. ft.�S 7� n Ca /tl1 • A % ft
Physical Address,City,and V5 r ft. ft : �t�W.,
�(�rt Iry 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) 22.Certification:36, Y8Y�9 N gp. Y?S /S W
6.Is(are)the well(s)1V.pPermanent or Temporary S, ed Well Contractor Date'
//�� F By signing this form,I herehj•car*that the ivell(s)was(lure)constructed in accordance
7.Is this a repair to an misting well: Yes oX-d
NG with ISA NCACO2C.0100 orISANCAC 02C.0200 Well Construr�on Standards anddrata
!frills is a repafr,fi/1 out known tell rnrutntction injonnatiaxplain the nature of the coN ofthis record has been provided to the ivell owner.
repair under 921 remarks section ar an die back of this form. 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 necessary.
drilled: c SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' 7 (it.} 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdifferent(example-3@200'and 2Qa 100) construction to the following.
10.Static water level below top of casing: �� (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing.use"+
1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. _(in.) 24b.For Infection Wells: In addition to sending the fonp to the address in 24a
.�,,,"� � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:_ (U I�vt y construction to the following.
('t.e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: Ir 24c.For Water Supply.&Infection 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: `A7 Z 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