GW1-2022-08419_Well Construction - GW1_20220826

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WELL CONSTRUCITON RECORD(GW-1) For internal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Well ContractorName FRONT TO DESCRWUON
4518-A I q5& 7
ft ft
NC WeII Contractor CertT=tionNambcr 19.OUTER CASING(for multi-cased wells)ORLIIVER tt a licable
Aqua Dr111,Inc. FROM To DIAMETER THICKNESS MATERIAL
R I.f 2Q ft in.
CompanyName n/ 16.1NNERCASINGORTUBING(geothermal close&4aa
2.Well Construction permit D�/V' / FROU TO DUMLE csr I T910ENOS I MATERIAL
List allappficable well construction permits(44 UIC,County,State.Variance,etc) IL a-
(n
3.Well Use(check well use): ft. & in.
Water Supply Well: M SCREEN
FRONI TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural 0Municipal/Mlic % in
Geothermal(Reating/Cooling supply) Residential Water Supply(single) ft. ft. iu
Industrial/Commemial 0Residendal Water Supply(shared)
18.GROUT
i-11trigation FROat TO MATERIAL EMPLACEMENT METHOD&ANIOUA'f
Non-water Supply Well: fL 5 IL G f
Monitoring Recovery ft. ft.
Injection Well:
tT. tw
Aquifer Recharge DGroundwaterRemediation
19.SAND/GRAVEL PACK(ifavotrilcsble
Aquifer Storage and Recovery E)SalinityBarrier FROM TO 51ATEML I EMPLACEMEh'CMEMOD
Aquifer Test [3StomiwaterDrainage ft. it.
Experimental Technology tOSubsidence Control tt &
Geothermal(Closed1oop) E..I T°— 20.DRILLING LOG attach additional sheets if nece
FR06t TO DESCRIPTION color,bardaess,sollfrack rain sim etc
_ Geothermal(Heating/Cooling Return) OUrer(ex lainunder#21 Remarks) D "L 117 IL CAS
4.DateWell(s)Completed: Ih1?-We1lID#I O / 1 L.
5a.Weil Location:
I iL it.
7014tn 56, n ft.
Faeility/OwnerName Facility ID#(ifopplicable) R' ft.
50 S�cSt;C� ft ft.
Physical Addms;s,City,,annd Tap ft. ft
QfAV1 ASQnk 21.REMARKS
County ParcelIden0cationNo.(FIN)
5b.Latitude and Iongitude in degrees/miautes/seconds or decimal degrees:
(if wctl field,one ladlong is su&icieot) 22.Certification:
M Aa.IS Zr? W
6.Is(are)the well(S)lWermanent or IOTemporary Signature ofCci ified Well Contractor Date
By signing this form,I hereby certify drat the svell(s)%,as(were)constructed in accordance
7.Is this a repair to an existing well: I�Yes or .._ o svith 15A NCAC 02C.0100 orISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fdlout known wen ca istmer on inf rs and explain the nature ofthe spy ofthisrecord has beenpravided to the weft owner. _ ° c i
repair under#21 remarks!section or on the back ofthisf me ry r. 1 _ ) r
23.Site diagram or additional well details: A x-� i
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
conshuction,onlyl GW-1 isneeded. lndicateTOTALNUMBERofwells construction details.You may also attach additional pagA61MSa��.'t. 2022
drilled. SUBMITTAL DMMUCTIONS
Unit
I'I T1iJY'P29�u� ��v�"fa•'br.i:
9.Total well depth below land surface.. 00 24a.For All Wells: Submit this form within 30 days oC$4tg"p)e QGDf well
Farmulb'pleweRs fist all dTlLsifdffferertt(example-3 OYan 2 1001) construction to the following:
10.Static water level below top of casing: / (ft) Division of Water Resources,Information Processing Unit,
Yivater level is above casing,use`+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL 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 form within 30 days of completion of well
12.Well o
construction method: I fi
(rat.-get.rotary,cable,directpasb,etc.)
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) 715 Method of test: rg 24.For Vyater Supply&Iniection 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.
Form ow-1 North Carolina Department of Environmental QuBnty-Division of Water Resources Revised 2-22-2016