GW1-2022-08750_Well Construction - GW1_20220516

WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Cameron Bazin
14:WATER'ZONES`.
FROM TO DESCRiP1TON
Well Contractor Name fL ft.
4518-A
NC Well Contractor Certification Number M OUTER.CASING' or multi-cased wells OR MINER tf a tie le:.':::'
Aqua Drill, Inc. FROM 2 TO D Rio. THrCltiVESS MATERIAL
Company Name 16.INNER CASING OR TUBING:( othermal closed-loo
2.Well Construction Permit o22 m7z FROM TO I DMbEETER I9HIC(QdFSS MwTERMI.
List all applicable well construction permits(Le.UIC,County,State,Variance,etc) ft. fL
3.Well Use(check well use):
Water Supply 17.SCREEN
PP Y Well: FROM TO I DI&NMER .. SLOTSITdi TH L.KrMaS IMATERIAL
Agricultural ,,,,D...,,,///MunicipaliPublic ft. R in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL ft, Sa
industrial/Commercial mercial Residential Water Supply(shared) 18 GROUT
.._Irri anon FROM I TO MATERIAL 6MPLACP.MENTMETROD&AMOUNT
Non-Water Supply Well: R. ft.
Monitoring QRecovery R. ft.
Injection Well: ft. fL
Aquifer Recharge oGroundwaterRemediation 19.SAND/GRAVEL PACK- -a hcabie .
Aquifer Storage and Recovery {Salinity,Barrier FROM TO ImPLACIEMEWMEMOD
__ Aquifer Test 3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control R. R.
Geothermal(Closed Loop) DTmcer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DFSCRIMON color,hardness,soillraek rain seas,eta
Geothermal(Heating/CoolingReturn) Other(explain undo#21 Rema>3rs) to ft. 70 fL
4.Date Well(s)Completed: Well IDR ft' TO iL
R. fL
5a.Well Location:
M04M W. ft C
Facility/Owner Name 1 Facility IM.(if applicable) / R' R
2s. Ae(fo✓1 1� Iy/K1�1��[. R. fL
OU
Physical Address,City,and Zip ft. ft Irlfoflrati0t1 Pry;
2L REMARKS
C44
County I Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,,one latllong is sufficient) 22.Certification:
6 77 �I N _9 W
6.Ware)the well(s)OPermanent or OTemporary Signaffm of Certified Well Conrrac�ol'r
(C_ r By signing this form,I hereby ccrtyy that the rvell(s)was(were)cautntandicted in and that
a
7.Is this a repair to an exist-mg well: Dyes or f/�No rv;dt 1SA NCAC 02C.0100 or 15A NCAC 02C.0100 Weil Constriction Standards and that a
Ijthis is a repai r Jlit out!mown well construction informatio and erplain the nature of the copy ojthis record has been provided to the well miner.
repair under#21 remarks section ar on die back of this form. 23.Site diagram or additional well detalls:
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
construction,only 1 OW-1 is needed. Indicate TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3os (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(sample-3Q200'and 2@1001 construction to the following.
10.Static water level below top of casing: �� (M) Division of Water Resources,Information Processing Unit,
Ifwaterlevel is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._�_Cn.) 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: I � construction to the following:
(i.e.auger,rotary,cabli:6 direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gym)_, Method of test: 24c For Water Suonly&Infection 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 GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016