GW1-2022-08932_Well Construction - GW1_20220919

--Printform
WELL CONSTRUCTION RECORD(GW--1) For Intemal Use Only.
1.Well Contractor information:
Cameron Bazin 14.WATERZONES i
WcllConitactorName FROM TO DESCRIPTION
NC Well Contractor CertificationNumber
StF I Q 202z I5 0EITERCASING formulticasedwells ORLIPIER tf,, licable
Aqua Nil,inc. FROM TO DL R THICKNESS MATERIAL
;•'lil'r'r:`^:rcf;;.:;: i pit O R. O ft 1,in.
CompanyName iO;on"rQ-.t
16.INNERCASINGORTIIBING •Wermaletosed-loop)
2.Well Construction Permit#: D l2 1 FROM To DIAMETER TIUCKNESS AUTERLIL
List alfapplicable well construction permits(ta Ufa County,Sta(4 Variance,eta) fL & in.
3.Well Use(checkwell use): ft. M in
Water Supply Well: 17.SCREEN I
FROM TO DIAMETER SLOTSiZE TRICKN6SS MATERIAL
Agricultural.
Municipal/Public ft ft �-
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) &
IndustriaVCommercial ;'Residential Water Supply(shared) 18.GROUT
_11crigation FROM I TO - MATERIAL EtnPLACEMENTMMMOD&A&TOUNT
Non-Water Supply Well: Q ft. 3 ft
Monitoring Recovery ft. fL
Injection Well: &I
AquiferRecliarge OGroundwaterRemediation
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK tf aticable Salinity Barrier FRoat To MATERIAL EMPLACEMEh i METHOD
Aquifer Test OStormwater Drainage M &
Experimental Technology E)SubsidenceControl R' & I .
Geothermal(Closed Loop) 0TIaCer 20.DRILLING LOG fattach additional sheets if necessegl
FROaf TO. DESCRIInkON color.hnrdcess;salurde& e, raia slzc.Cie.)(HeatinglCooling Return) .ONier(explain ender#21 Remarks)
4.Date Well(s)Completed: Well IID# tap ft. S fr
5a.Well Location: R'
Facility/Owner Name FaciUWID#(Tapplicable) ft• R'
PhysiralAddress, %audZip &
21.REMARKS i
County Parcel Identification No.(PIN)
I
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees-
(irwwelll field,one latAong is sufficient) o f r9 L 72.Cerlifieadon-
T 4, i2 7 5 r
6.Is(are)Mewe0(S) Permanent or ©1Temporary SignatumofCedifiedWellContractor i Date
7_ By syontng this form,l hereby certifp that the wells).uvs(were)constructed in accordance
7.Is this a repair to an existing well: IlYes or No ivith 15A NCAC 02C.0100 or ISA NCAC 02C.0200!hell Construction Standards and that a
ffthis is a repair,ftNmetktorvn well construction rnformati and explain the nature ofthe copy ofthis record has been provided to,the%Wl owner
repair under#21 remarks section or on the bark ofdrEvforat. i.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also'attach additional pages ifnecessary.
duilled:
2�S SDBMITPALINSTRII MOM
9.Total well depth below land surface: 00 24a.For All Wells: Submit this form withiri 30 days of completion of well
Formalaple ivelk list all depths rjdifferent(example-3@200'and2@1001 construction to the following:
`I
Cr
10.Static water level below fop of casing. o (ft) Division of Water Resources,Information Processing Unit,
Ylvater level is above casing use+" 1617 Mail Service Center,Raleigh,NC 27699-1617
U.Borehole diameter.
(in.) l I 24b.For Injection Webs: In addition to sending the form to the address in 24a
12.Well construction method: '1 O t r/1�►/ above,also submit one copy of"form within 30 days of completion of well
tee.Well rotary,uc cable.d method:etc:) construction to the following.
Division of Water Resonrces,iUkderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: !{{ f7' 24c.For Water Supply&infection Wells: In addition to sending the form to
j the address(es) above, also subrilitl one copy of this form within 30 days of
13b.Disinfection type: Tr Amount: completion of well construction to the county health department of the county
where constructed
Form GW-1 NorthCarolina Department of Environmental Quality-Division of WaterResomces Revised 2-22 2016