GW1-2022-07587_Well Construction - GW1_20220815

Prin#Form
— -WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Informationa. I I
i
Cameron Bazin 14.WATER ZONES
Wft.
TO DESCIUPTION
well contractor Name ft.
4518-A fr
NC Well Contractor Ce14flcation Number is.OUTER CASING for multi-cased wells OR LINER f—applicable)
Aqua Drill,Inc. [ROM To DIAMIiTFR TfficKNEss MATERIAt
O ft. O ft. in.
Company Name 16.INNER CASING ORTUBING eothermal closed400pL-
2.Well Construction Permit#: FROM TO DIAMETER ITffit2QtESS MATERIAL
List all applicable wolf coustmcdon permits(1.a UIC,County:State.Irarianc4 etc) ft. in
3.Well Use(check well use): ft to
Water Su Well: 17.SCREEN
PP�Y FROM TO I DIAMETER I'SLOT SIZE I THICKNESS IMA'I�RIAL
DAgricultural DMunicipaUPublic 1L 8. in.
__Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft
Industrial/Commercial /—,Residential Water Supply(shared) 18.GROUT
i-11trization FROM I TO MATERIAL EMPLACEMENT ME ROD dr AMOUfrf
Non-Water Supply Well: O 2 ft, j
Monitoring Recovery M fL
Injection Well: fL &
Aquifer Recharge EiGronadwater Remediation
19.SAND/GRAVEL PACK a cable
Aquifer Storage and Recovery DSaliaity Barrier FROM TO atATERIAL EMPLACEMENT METHOD
Aquifer Test OStoinwater Drainage
ExperimentaiTochnology E)SubsidenceControl ft.
Geothermal(Closed Loop) [ITracer 20.DRIELLiNG LOG attach additional sheets if necessary)
Geothermal(Heating/Cooting Ream) Other(explain under#21 Remadrs) FROM DEscRlt'<toN cocci Gardners soturock nto sin etc
r� & y ft.
4.Date Well(s)Completed: Z Well MN 0 R' / ft
5a.Well Location:
S�o�+wrxs�b ft. ft. ' • —
Facility/OwnerNate n Facility W#(if applicable)
ft. ft. v
Physical Address,City,and.21p
21.RF1tLenuc
You kin
County ParcelIdentificationNo.(PIN)
5b.Latitude and longitude in degreesdminutes/seconds or decimal degrees:
(if weal field,one lattlong is sufficient) 2L Certification:
Y? 1Y 8D. 5Y72S w �2� t' ` Z
6.Is(are)the wells) Permanent or (Temporary Signature o CeRified well ContMet" Date
By signing ibis form,1 hereby codify that the well(s)xos(were)constructed in accordance
7.IS this a repair to an existing well: )Yes or .._ No wfth I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fin out known wen construction informat'n and explain the nature of the copy ofthis retard has been provided to dw well owner.
repair under 921 remarks section or on the back of thisform
23.Site diagram or additional well details:
S.For GeoprobedDPT 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / ( ) 24a.For All Well Submit this form within 30 days of completion of well
For muNple wells list all depda fdrfferem(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing. t7 (N Division of Water Resources,Information Processing Unit,
Ifwarer level is above casing,use`+" 1617 NUU Service;Center,Raleigh,NC 276994617
1L Borehole diameter. (in.) 24b.For Infection Webs: In addition to sending the form to the address in 24a
6 � above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: I1 construction to the following.
(Le.auger,rotary,cable,direct push,ere.) IF
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 Method of test..� _ 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
136.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