GW1-2022-08527_Well Construction - GW1_20220519

WELL CONSTRUCTION RECORD(GW--1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 1a:WATER'ZOPiES.
Well Contractor Name FROM TO DESCRIPTION
451 S-A ft• ft.
ft, ft
NC Well Contractor Certification Number 15.OUTER.CASING for multi-cased wells:OR-I iNER if a' lidable'•'.:"
Aqua Drill, Inc. FROM I TO I D R TFIICKNESS I MATERIAL
p ft. o ft in.
Company Name
16.INNER CASING ORTUBING' � "tbermalaosed-lo - -
2.Well Construction Permit#: o��``�! FROM To I DIAMETER I THICKNESS I MATERIAL
List all applicable Neil cahrstruction permits ii.e.UIC,County State.Variance,etc.) R. fL in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN' ;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
lGeothermal(Heating(Cooling Supply) VIResidential Water Supply(single) ft It in.
- IndustriallCommereial oResidential Water Supply(shared)
18.GROUT ':.,
In't atioa FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft'
24 .ft
Monitoring ORecvery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge DGroundwatcrRemediation
19.SAND/GRAVELPACK ff a livable .
Aquifer Storage and Recovery [Salinity Barrier FROM TO MATERL4L I EMPLACENIENI•ME-MOD
—Aquifer Test 08torruwaterDrainage ft. fL
Experimental Technology OSmbsidence Control ft fL
Geothermal(Closed Loop) 1©fTracer 20.DRILLING LOG attach 2dditional sheets if aeces •
Geothermal(HeatingtCooling Return) in Other(explain under#21 Remarks) FROM To DESCRIPTION mler,hardy—,sniltruch type,Rmin sac.-tr.
O ftso ft
4.Date Wells Com feted: / �2 'e01D ft. S it
O p VL # D y
Sa.Well Location: /� 'lnry, tt ft
A((is Pf N , fL ft
Facitity(OwnerName Facility lDR(ifapplicable) A,/ ft ft
�2I;.. 11eed.lare, rl 4'.w At!414/ /Yc..- ft. +ftL --
Physical Address,City,and Zip ft !Q 7
O L"a✓t 2L REMARKS '
County Parcel Identification No.(FIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwellfield,one Wong is sufficient) 22.Certification:
3S-91117 N ri 3
6.Is(are)thewe0(s)ffPermanent or OTemporary Signature of Certified Well Contractor
By signing this fonn,I hereby carify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing wen: E)Yes o No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 WeR Construction Standards and drat a
If this is a repahr fell otd knonm well construction infannath h and explain the nature of the rop},ofthir record has been provided to the well a,vner-
repair ender#21 remarks section or on the back ofthis form
23.Site diagram or additional well details:
S.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 TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary-
drilled: Ct SUBMITTAL INSTRUCTIONS
9.Totalwell depth below land surface: 1 s (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfjerent(example-3Q200'aand 2Qa 1001 construction to the following.
10.Static water level below top of casing: / o UP Division of Water Resources,Information Processing Unit,
Ifivaterlevel is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._�On.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
R above,also submit one copy of this form within 30 days of completion of well
(L.Well construction method: •// construction to the following:
(Le.eager,rotary,cable,,directpmuh,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) I 0 Method of test.1361CIl2 e, � 24c.For Water Suvplv.&Iniection Wells: In addition to sending the form to
r 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. j
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016