GW1-2022-08596_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For Intemai Use Only.
1.Well Contractor Information:
Cameron Bazin 14:wATERZONEs. r.
FROM TO I DESCRIPTION
Well Contractor Name fL
4518-A ft. It
i,
NC Well Contractor Certification Number 15.OUTER.CASING' ormalti-cased,'sveRs ORL'IlNER da
Aqua Orill,Inc. FROM To DIAMETER rS1CiS1�Ss MATERIAL
in.
Company Name
n 2�O 16.INNER CASING'UR TUBING: othermal closed-loo
2.Well Construction Permit#: N L!� FROM TO DIAMETER 'rmctavess MATERIAL
List all applicable well construction permits f.e.WC,County,State,4ariance,etc) ft ft In.
* in.
3.Well Use(check well use): ft. ft. 11
Water Supply Well: FROM TO DIAMETER sLorsl2� TffiCKNESS ntATERw
:)Agricultural ©iMunicipal/Public ft. & in.
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) fL ft Iu
Industrial/Commemial tgResidential Water Supply(shared) 1S.GROUT
Irri ation FROM TO MATERIAL EMPLACEMEW E'rHOD&AMOUNT
Non-Water Supply Well: 0 ft' 2-1
ft
Monitoring Recovery ft. ft.
Injection Well: ft. fL
Aquifer Recharge OGmundwater Remediation
19.SAND/GRAVEL PACK ifa licable .
Aquifer Storage and Recovery 08alinity Barrier FROM To MATERIAL ENrpLACEMENTMLTHOD
_. Aquifer Test ®IStormwater Drainage ft' ft.
Experimental Technology OSubsidence Control - ft' IL
Geothermal(Closed Loop) DTracer 20.DRII LING LOG attach additional sheetslifnecessRgl
Geothermal(Heating/Cooling Return) : Othcr(explain under#21 Remarks) FROM (t. To DESCRIP ION eotor tmrdaess soturoch a in avt.et
30 IL fAde!
4.Date Well(s)Completed: Well IDR ft. ft.
ft. ft.
5a.Well Location:
ft �t
Facility/Owner Name W- 7 Facility ID9(if applicable) R' ft'
VA
Physical Address,City,and zip rL fL inkanako PrmgCy i Ura
2 y 2LREMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
3� N 80 fos �a W
6.Is(are)the well(s)�Permanent or OTemporary Signature of Certified Well Contractor ! Date
By signing this form,I hereby certify that the wells)was(u oe)constructed in accordance
1.Is this a repair to an existing well: lYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C AZ00 Wall Construction Standards and that a
if this is a repab;fdl out lmoam cell cottstntetion infoma and explain the nature of the copy oJthis rernrd has been provided to the well owner.
repair wider 921 remarks section ar on the back of thisform. 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: SUBMITTAL INSTRUCTIONS
t
9.Total well depth below land surface: toes (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For maltiple wells list all depths ifd8erent(example-3@200'and 2@100� construction to the following:
(ro
10.Static water level below top of casing: (ft) Division of Water Resorirces,Information Processing Unit,
lfwater level is above casing,use'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.Far 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 construction method: rOfr� 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
Cr
13a.Yield(gpm) 20 Method of test: / 1/ 24c.For Water 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: 6c/� Amount: wv� completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Enviroumcntal Quality-Division of Water Resources Revised 2-22-2016