GW1-2022-08236_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only-
1.Well Contractor Information:
Cameron BaZin 14:WATERZONES
FROM I TO DFSCRiI'TION
Well Contractor Name Z @. I t
451 B-A ft. fL 1 7
NC Well Contractor Certification Number M OUTER CASING or mniti-caaed iveDs ORLINER
Aqua Drill, Inc. FROM T D R THIL7�SS MATERIAL
ft. 16 0 fL in.
Company Name n 16.INNER'CASING'ORTUBINGI "thermal closed-lot
!X
2.Well Construction Permit#: 2 10 2�S 2'" FROM I TO IDTAMErER I TIUCtQ M I MATERIAL
List all applicable well construction permits fl e.UIC,County,State,variance,etc) ft I % In.
in.ft
3.Well Use(check well use): fL
Water Supply Well: n7RE":11P DIAMETBR I SLOTSI7.S THICKNESS Mprcurer._.Agricultural DMunicipal/Public fL in•Geothermal(Heating/Cooling Supply) Residential Water Supply(single) It. ia.Industrial/Commercial Residential Water Supply(shared)ation O MATERIAL EMPLACEMENT METHOD&AMOUNT
f- Aquifer
ater Supply Well: 0 ft. 2 S ft.
itoring Recovery fL R
on Well: g, ft.
Recharge oGroundwaterRemediation 19.SAND/GRAVEL PACK rfa Hcable .fer Storage and Recovery DSalinity Barrier FROM To MATERIAL BMPLACEMENT MEr'HOD
Aquifer Test [3Stormwater Drainage R' ft
Experimental Technology Subsidence Control R•
-- Geothermal(Closed Loop) Tracer 20.DRILLING'LUG attach additional sheets if necessary)
FROM TO DESCRIPTION color hardness,soillroalc 4 in ' Me.
Geothermal(Hosting/Cooling Return) Other(explain under#21 Remarks) FROM
ft- ft JC
4.Date Well(s)Completed: 1 Q' Well ID# 7 n• 32� ft �►
5a.Well Location:
ft. fL (�
Facility/O Name G Facility ID#(if applicable) 1 ft' IL 2022
Physical Address,City,and tip fL M
2L REMARKS
Sotlrl/
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Cifwell field,one ladlong is sufficient) 22.Certification:
36,y�98 N R��, 6Y2-SS W
6.Is(are)the weU(s) Permanert or OTemporary
Signature of Certified Well Contractor Date
By signing this form.I hereby test fy that the well(s)seas(use)constricted in accordance
I.Is this a repair to an existing well: Dyes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consinrcrion Standards and that a
If ibis is a repair,fill oat known well construction informatiaw'andd explain tare nature of the copy ofthis r'eenrd Isar been provided to the swell owner.
repair under P21 remarks section or on the 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 i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUSUBMITTALINSTRUCTIONS
9.Total well depth below land surface: 395 (ft-) 249.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Tdayerent(erample-3 uQr 200'and 2@ 100) construction to the following
10.Static water level below top of casing: 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this fonts within 30 days of completion of well
12.Well construction method: /w fo i V construction to the following:
(i.e.auger,rotary,cable,direct push,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test: �7MG kG 24c.For Water Suonly&Injection Wells: Tn addition to sending the form to
/.� 'Moe
' the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: r'T _ AmormC `S/p Z completion of well construction to the county health department of the county
where constructed-
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources' Revised 2-22 2016