GW1-2022-08400_Well Construction - GW1_20220519

i
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only
1.Well Contractor Information:
i
Cameron Bazin 14:waTERzoIVEs. -
WellContractorName 4 FROM TO DESCRIPTION
4518-A ft. it 6-pnz
NC Well Contractor Certification Number
15.OUTERCASING'formnllf-cascif��vells'ORI:INER rfa limlile)•'.:'•. ':
Aqua Drill., Inc. FRONT I TO DLVriETL•R THIL'fINEss MATERIAL
Company Name
O ft. tt in.
-16.INNER CASING OR TUBING(ebthermal closed-loop)
Z.Well Construction Permit#: W rneo7 FROM I To I DUNMTER I THICKNESS I MATERIAL'
List all applicable well construction pern+its(Le.UIC,Conn%State irarianm etc) ft f6 In.
3.Well Use(check well use): ft fG in.
Water Supply Well: 17.SCREEN'.:
FROM TO DIAMETER 'SLOTS= TH1CtINESS MATERIAL
Agricultural ;©lMunicipal/Public ft it in.
Geothermal(Heatmg/Cooling Supply) Residential Water Supply(single) ft It in.
IndustriaUCommercial DResidential Water Supply(shared) Is.GROUT
`Irri ation FRONT TO MATERIAL EMPLACEMENT ME MOD&AMOUNT
Non-Water Supply Well: & 2'?,it C
Monitoring ORecovery & iL
Injection Well:
fti it
Aquifer Reebarge DGmundwaterRemediation
uifcr Storage and Recovery 19.SAND/GRAVEL PACK if n licable .
A
qery Salinity Barrier FRONT To I MATERIAL I EMPLACEKENTMETHOD
DAgtuferTest tOStormwaterDrainage It. ft
FlExperimental Technology OSubsidence Control It ft
BGeothermal(Closed Loop) ©iTracer 20.DRILLING LOG attach additional sheets if necessa
Gcothermal.(Hcatin(Cooling Return) Othcr(explain under 421 Remarks) FROM To DESCRIPTION(color,bardnms.soivrock typp,p=ln sire-etc.)
C n ft ft S
4.Date-Veu(s)Completed:�J, -�ielllDn �0 ft 90 s ft
5a.Well Location:: /� TT ft. fr.
ft %
Facility/OwnerName FaciliryID:r(ifapplicable) ft. ft.
Physical Address,City,and Zip IL
ft ' ' '
P��Ni 21.REMARKS MAY
/J
County x Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Ctfwell field,one lat/lono is sufficient) 22.Certification: e1 Y7::-•;, ;"','"i 1 t"i i
7� 3t3o� 79. 6'Yz W . . ,,2 ,;
6.Is(are)the we1l(s) Permanent or Temporary Stgoanue ofCerttfie ell Contractor t Date
BF signing this form,I hereby certify thar the rveil(s)was(were)rnrutruaed m.accordance
?-Is this a repair to an existing well: [3Yes or, No with ISA NCAC 02C A100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repau•,fll o0tknoam irelf coustnrctian.in•formatiot(an—d erplatn the naurre ofthe COPY offhis record has been provided to fhe well mvner.
repoh-Imder tr21 remarks section or on the back,ofthfs fort, -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 TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
drilled:
SUBiVIITTAL 1NSTRUCTIONS
9.Total well depth below land surface: S 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells lit all depths ifdifferem(erample-3@200*and 2@100� ( ) construction to the following:
10.Static water level below top of casing: Sd (ft) Division of Water Resources,Information Processing Unit;
If water level is above casing,rise"T" 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
12 Well construction method: above,also submit one copy of this form within 30 days of completion of well
b V�'Glt��/
(Le.auger,rotary,cable,direetpush,cta) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) [V Method of test 57/ AV- 24c.For Water Suonly-&Injection 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: 0� completion of well construction to he county health department of the county
where constructed.
Form OW-1 North Carolina Department ofEavironmeatal Quality-Division of Water Resources Revised 2 32-2016