GW1-2022-08943_Well Construction - GW1_20220919

_Print Form_
WELL CONSTRUCTION RECORD(GW 1) For btemal Use Only: i
1.Well Contractor Inforination:
Cameron Bazin 14-WATMZONFS
Well Contractor Name a ' ° .-..L,/ FMb' TO DESCRIPTION
IL ft.
4518-A SEP a 2022 Zos �. IL
NCWeUContractorCettificationNcmber 15.OUTTERCe4SIATG(for maiHeasedweUs ORLIIVER Ifa ►icable
�rliGi tC 1 �i�`C�va:1. Ut 4 FROrt TO DL4&SETEIt ' tffiCKNESS MATERIAL
Aqua Drill,Inc. �,,r 0
it. y e ft i iu.
CompanyName 16.DMRCASINGORTUBING( thermaldoseddoo
2.Well Construction Permit#. t:lll�(O� ]FROM TO DiAMElER TEUCEMESS MATERIAL
^^,,///`'
Llst alt applicable well cwatrucdon permits(i.e.UIC Countlt Stag Varlanc4 eta) % IL i In.
3.Well Use(cheekwell use): % + in.
Water Supply Well: 17.SCREEN
FROM TO I DrAMMR I SLOTS= I TRICKNESS I MA7ERL\L
3Agricultimll DMunicipal/Public R is
Geothernurl(Heating/Cooling Supply) JffResidenfl2l Water Supply(single) ft. ft
IndusWaUCommencM Residential Water supply(shared) 18 GROUT
11higation FROM TO MATERIAL EMPLACEMNT hMMOD&AMOUNT
Non-Water Supply Well: to R
Monitoring DRecovery R. ft.
lExperimental
tion Well;
uiferRechatge DGronmdwaterRemediationuifer Storage and Recovery �"'�Salioi B � 19.SANDlGRAVEL PACK tf a h'cabhe�p ty FROM TO MATERIAL EMPLAC04M METHOD
fTest 0St-raw-terDrainagett Technology OSubsidence Control ft ftothermal(ClosedLoop) E3Tracer 20.DRlLLINGLOG MAecessaiA
othermal(Heating/Cooling Return .Other(explainunder#21 Remarks) FRDIrtio TO DESCRIPTION(color.aoraa�,sotureck euta size Ma
ft &
15
4.DateWell(s)Completed: v Q /
r"(�Wellm# ft &
5a.Well Location: % ft
VrifOt/N�G �pt(,aJ� ft. ft
FacilitylOwnerName Facility
yll�D#(ifapplicable) & %
put— ff�Ml►t^ _ 0<I®/ Ar, ft. ft
PhysicatAddress,City,and Zip K• %
ZL REMARKS
County ParcelidentificationNo.(PIN)
5b.Latitude and longitude in degrees/tnlnutes/seconds or decimal degrees:
(ifwell field,one latnong is sufficient) 22.Certification:
6.is(are)thewell(s) ermanent or IOTemporary SignaturcofCcr6fiedWell ontmotor i
By signing this form,I hereby eertifj that the uell(s)xnt{tirere)constructed in accordance
7.Is this a repair town existing well: I©Y¢S or .__ No with ISA NCAC 02C.0100 or 15ANCAC 02C.0200!Yell Construction Standards and drat a
Ifthis is a repair,fill out Imoxm well construction informati and erplainAke nature ofthe copy ofthirrecord has been provided to the nwil owner.
rq rwider#21remarkssectionareathebarkofdrisfo 23.Site diagramor additional welldetails:
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 ifnecessary.
drilled SUBAN1TALINSTRUCTIONS
9.Total well depth below lead surface: !i 2 y4a,For All Wells: Submit this'form within 30 days of completion of well
For ' e ivelk 1W all rf ff ( p (a)2 (a)I 61 (4) p
lap! depdrs'di erent emm le-3`00'and 2 0 construction to the following:
10.Static water level below top of using: r b (M) Division of Water Reso Trees,Information Processing Unit,
Ifwaterlevel is above casing rise+/" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 24b.For Infection Wells: In addition to sending the form to the address in 24a
12 Well construction method: _ �'G1Jry above,also submit one copy of this form within 30 days of completion of well
(i.e.auger;rotary,cable,d'aectpush,etc) construction to the following
i
Division of WaterResonrces,Underground Injection Control Program,
FOR WATER SUPPLCY,WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Will) 7 d Method of test: /f 24c.For Water Supply&Iniectioir 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:-9-10 Amount: completion of well construction to the county health department of the county
where constructed.
FormGW-1 NorthCarolina Department of Environmental Quality-Division of Water Resources; Revised 2-22.2016
0