GW1-2022-09114_Well Construction - GW1_20220926

WELL CONSTRUCTION RECORD(GW 1) For internal Use Only: Print Farm
1.Well Contractor information:
Cameron Bazin 14.WATER ZONES
Well Contractor Name FROM TO I DFSCRU'rION
451 s--A YO
ft
NC Well Contractor Certification Number ft.
15.OUTER CASING(for multi-cased wells)OR LINER fif a livable
Aqua Drill,Inc. ]FROM TOr/ DIAMETER TLncxNEss MAT'ERyIA.L
CoutpanyName � ��
ft r O� in. PIS
t5 16.INNER CASING OR TUBING(eoth--- closed-loon)
2.Well Construction Peru#: FROM To I DIAMETER I THIt30V6S5 MATERIAL
List all applicable well canrrructiaa pennies#.a Ult;Comtg:SW4 Varianm etc) ft & In.
3.Well Use(check well use): tL fL in.
Water Supply WeU: 17.SCREEN
•-,Agricultural FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
lttlicipal/Pnblic ft. in:
Geothermal(Heating(Cooling Supply) Residential Water Supply(single) (L ft in.
Industrial/Commercial OResidentiat Water Supply(shared)
lti.GRODT
` Irrigation, FROM TO MATERIAL E51PrACEMENT METHOD&AMOUNT
Non-Water Supply wen: D ft, fL G
l Monitoring 0 Recovery ft, g
Injection Well:
Aquifer Recharge ft' IL
q rb'e �GronndwaterRemediation
Aquifer Storage and Recovery19.SANDIGRAYII.PACK if a Gcable
OStormw terDr FRODi TO MATERIAL EMPLACEMENT METHOD
Aquifer Test �StormwaterDrainage ft R
Experimental Technology [3Subsidewe Control ft. ft
Geothermal(Closed Loop) [3Traeer 20.DRB 1 IIYG LOG attach additional sheets if nece
Geothermal(Heating/Cooling Return) MOther( lain under#21 Remarks) FROai To I DESCRTPTrory color hardaen.wlurock type,graln Am etc
Q R O 1L
4.Date Well(s)Completed: 7 G4.WeIIM# fL �J
Sa.Well Location: fL fL
r u.
Facility/OwnerName F—UrY 1D#(ifapplicable) & fL
!�/`f ft' — ai
Physical A s,City,and Tap �— ft fL t
&
zl.REhIARKS
County ParcelIdeniificationNe.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Certification:
3a , v YZzS N go. S'3d o!
6.Ls(are)the well(s) ermanent or IOTemporary Signature ofCertified well Contractor Date
By signing this form,!hereby cerXfp that the weff(s)cons(svere)constructed in accordance
7.Is this a rep an existing well: )Yes or No with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
lfthii is a repair,fill out bwivn iveU cowuucdon informatio and eclairs the nalure of the cope'ofthis record has been provided M the well owner
repair under#21 remarks section or on the back ofthisform.
23.Site diagram or additional well details:
8.For Geoprobe/11PT 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 dam•You may also attach additional pages ifnecessary.
drilled:
S n WBMITTAL fNSTRIICTIONS
9.Total well depth below land surface: G G (B) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list aR depths ifdifferem(example-3Q200'and 2@100)
construction to the following:
ljsvater level is above casing,rue
Static water level below top of casing: y (ft) Division of Water Resources,Information Processing Unit,
"+^ 1617 MeU Service Center,Raleigh,NC 27699-1617
11 Borehole diameter. (m.) 24b.For Injection Wells: In addition'to sending the form to the address in 24a
12 Well construction method: m I � above,also suborit one copy of this form within 30 days of completion of well
([Le-aogar;rotary,cable.dinxtp-b,etc) construction to the following:
FOR WATER SUPPLY WFLbS ONLY; Division of Water Resom ces,Underground Injection Control Program,
[' 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of best: ly 24c.For Water go&&Injection Wells: In addition to sending the form to
the address(m) above, also submit one copy of this form within 30 days of
136.Disinfection type: Amount: ?� completion of well construction to the I county health department of the county
where constructed.
Form GW-1 North Carolina Department of Eovfronmoatal Quality-Division of WaterResources Revised 2-22-2016