GW1-2022-08597_Well Construction - GW1_20220519

WELL CONSTRUCTION RECORD(GW--I) For internal Use Only
1.Well Contractor Information:
Cameron Bazin 14.WATER'ZONES•-.
Well ConmetorName FROM TO DESCRIPTION
4598-A ft. ft
NC Well Contractor Cer0cation'Number
15:OUTF.RCASING'formal&-caseH=welts-ORT:INER tfa lir�lile -'-.'-: •''..
Aqua Drill, Inc. - FROM To DIAMETER THICKNESS nATERIAL
ft. 7� ft tn.
CompaayName c+
©O � 75 16.11\'NERCASINGOR TUBING I ebthermaiclosed-Soo . . -
2.Well Construction Permit# J PROM TO DIAMETER. THICKNESS MATERIAL
Lint all applicable vve11 construction permits(La UIC,CotmtR State,irariancq ate) ft. ft In.
3.Well Use(check well use): ft ft so.
Water Supply Well: i7.SCREEN'.
FROM TO DMMKTGR SLOTS= THICKNESS MATERIAL
Agricultural 01dunicipal/Public ft. ft in.
Geothermal(Heating/CoGling Supply) - esidential Water Supply(single) R
_Industrial/Commercial DResidenlial Water Supply(shared)
1&GROUT
Irri ation FROM TO MATERIAL EMPLACEMENTMETROD&AMOUNT
Non-Water Supply Well, '0 ft G/1 S
Monitoring ORecovery f. ft.
Injection Well:
AquiferRecbarge 0(iroundwaterRemediation
19.SAND it
/GRARELPACK Ifa livable). .
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEhtENTN11=03
Aquifer Test 08torinwaterDrainage it. ft
Experimental Technology Subsidence Control ft %
Geothermal(Closed Loop) Tracer 20.DRII,L'INGLOG attach additional shears ifnecessa ..
FROM TO DESCRIPTION colas hardness.wittrack e, rrin sax.etc)
_.Geothermal(ReatinJCooling Return,) Other(explain under#21 Remarks) O ft To 'L
i
4.Date Well(s)Completed: 3 2 2. Weil]DO 30 ft. .24g ft
Sa.Well Location: ft. it
(.-s"AA0r ft ft
Facility/Owner Name �Q FacilftylM if applicable) 0• ft.
2 yl /�7`I��tdlSc� / ��0►1�� /�G tt, it ` - r*a
Physical Address,City,and Zip ft ft
G 2L REMARKS ~
d/ 7
County Parccl Nentificatioallo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfieU one latnongissufficient) 22.Certdtcation: u- ''��'iI1L' 1 :Ill''c,• ,.�
51 3308S N cgs.862. 3 T '.-
W
6.Is(are)Abe well(s) t"rermanent or Temporary Signature of Certified Well Contractor Date
9T By signing this fann,Ilrereby eertrrYy that the well(s)was(here)constructed in accordance
7.Is this a repair to an existing well: OYIs or zko with 15A NCAC 02C.0100 or ISA AICAC 02C.0200 Well Construction Standards and that a
IfIlds is a repair,fdl out Amoan well construction infonnertlettfand erplain the nature ofthe copy oflhis record has been provided to the.well owner:
repair under'21 retnarb section op:on die back ofthfsfami
23.5ite 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 TOTALNUMBER of niells construction details.You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_IMS (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@2oo'and 2Qo 1 oo) construction to the following:
10.Static water level below tap ofeasing: sv� A) Division of Water Resources,Information Processing Unit,
IJwaterravel is above casing:use"r" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 bays of completion of well
12.Well construction method: (ID�f construction to the following:
(Le.auger,rotary,cable,direct push,eta.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ♦( � 1636 Mail Service Center,Raleigh,NC 2769 9-1 6 3 6
13a.Yield(gpm) Method of test: 6CAC��a.. 24a For Water Supply-&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_: 19P t? completion of well construction to Ithe county health department of the county
where coustructed.
Form GW-1 North Carolina Department ofEnvimnmcntal Quality-Division ofWatcrResoucces Revised 2 22 2016