GW1-2022-08465_Well Construction - GW1_20220510

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Prin3 Forrn° ;� �:
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron BaZirl .14i WATER ZONES".
FROM TO I DESCRIPTION
Well Contractor Name ft. c fL
4518-A ft. 7 ft p
NC Well Contractor Certification Number :15iOUTER':CASING'formulti-eased;wells'ORLINER 'a
Aqua Drill, Inc. FROM TO I DIAMETER I THICWaSS MATERiAI,
ft. I y0 fL in.
Company Name ^ � 1:16.INNER CASINGORTUBING` - ermatclosed=loo
'(� O
2.Well Construction Permit#: G FROM 'r0 DIAMETER THICKNESS MATERIAL
Lust all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft• ft In.
3.Well Use(check well use): ft. ft. is
Water Supply Well: FROM
T SCREE
PP FROM TO DIAMETER SLOTSI7d: rH1CKNFSS MArcmet.
Agricultural IOMunicipaUPablic ft. fL in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL fL to
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring ORecovery ft• ft
Injection Well: ft. %
Aquifer Recharge Groundwater Remediation
.19.SAND/GRAVEL PACK ds'Ucable
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL EMPLACEMF,TII'METHOD
Aquifer Test 0Stonnwater Drainage ft. fL
Experimental Technology OSubsidence Control fL fi,
Geothermal(Closed Loop) OTtacer 20.DRULLING LOG attach additional sheets If necessary)
FROM I TO DEscRrrrrory
Geothermal(Heating/CoolingM Return) Other(c lain under#21 Remeaks) rnmr, sotUmek m ' etc
ft. 70 ft.
4.Date Well(s)Completed: 1112f-121- WeO ID€/ ft. qw� ft.
ft. it.
Sa.Well Location:
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft' ft.
2Yo A4601 94 Moy.'so�,, &
Physical Address,City,and Zip fL IL
Ace A%a f_ 2L REMARKS
County /� Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certification:
N W
6.Is(are)the well(s) rmanent or Temporary
PSignature of Certified Well Contractor I Dare
By signing thus form,I hereby cert�that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes orMNo with I SA NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informatto and explain the nature of the cop)'of this record has been provided to the well owner.
repair under#21 rmarks section or on the back of thus form. 23.SIte diagram or additional well details: 19CE�
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional p if n essary.
drilled: r� SUBMITTALINSTRUCPIONS ZQ21
9.Total well depth below land surface: 2 S (R) 24a.For All Wells: Submit this'form within 0 a
For multiple wells list all depths ifdffferent(example-3@2`00'and 2@100) construction to the following.
10.Static water level below top of casing: /00 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use'+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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 construction method: / �'� construction to the following:
(i.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) 2 S Method of test: V Ctl1Jta - 24c.For Water SupDlv-&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: /`pZ 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 E Revised 2-22-2016
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