GW1-2022-09198_Well Construction - GW1_20220930

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use only.
1.Well Contractor Information
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DPSCREMON
451 B-A ft ZtS ft 5
ft. R
NC Well Contmetor Certification Number 15.OUTER CASING formaifi cased wells ORLINER,f a Ifcable
Aqua Drill,Inc. FRoM To D resit icNEcs MATERIAL
CompanyName ft. I-leo ft in
022,14 16.DMRCASLNGORTUBING thermaldme"oo
2.Well Contraction Permit#: FROM To DwMETPR rymckNtss r MnTERtAL
List all applicable-11 construction permits r e.flltti Cotmt}+,state Variance,eta) & % In.
3.Well Use(checkwell use): ft. fL in.
Water Supply Well: 17.SCREEN
. 1 FROM TO DIAMETER SLOT SIZE THICKNESS MATERTL
MunicipaMblic & in.
Geothermal(Heatiog/C001iog Supply) esidential Water Supply(single) & ff. in.
lndustrial/Commencial Re:sidential Water Supply(shared) 18.GROUT
hri tiaa FROM TO MATERIAL EMPLACEMENT METHOD&AMOUh-r
Non-Water Supply Well: Q ft s' % 6hII
Monitoring E3R=ovcy & g
Injection Well:
Aquifer Recharge 'o.GroundwataRemediation
Aquifer Storage and Recoverygalini ganict 19.SAND/GRAVEL.PACK d'a livable
tY FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage tt• &
Experimental Technology Subsidence Control IL ft.
Geothermal(Closed Loop) DTM= 20.DRILLING LOG tattacli additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other( lain under#21 Remarks FROM TO DESCRWMN solar nuaam solvruck tne,grda size ern
.40 & 9 %
4.Date Well(s)Completed: ell ID# ft• f ft.
Sa.Well Location: ft fr
rr+-
FaciGty/OwoerNeate Facility ID#(ifapplicable)
3203 R 0_aR0Q irk 1%h-Sen ft. E.
Physical Address,City,andZip M ft _. e. _
f u 21.REMARKS
County Parcel Identification No.(PIN) r +
Sb.Latitude and longitude in degreestminutes/seconds or decimal degrees:
(if wcll field,one latnong is sufficient) 22.Certification:
3G.3o eV y2 n 8oG�9�Ga -W
6.Is(are)the well(s)OP-manent or iOTemporary Sigaamre ofCertified Well Contractor Dad
B),signing this form,I hereby cer(lfl+that the ivell(s),vas(were)constructed in accordance
7.Is this a repair to an existing well: I®Yes or PIN. ivith 15A NCAC 02C.0100 of ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repalr,fill out known well construction f yormaIlAi_d euplain the nature of the spy ofthis record has been provided to the%vil owner.
repair under 921 remarks section or on the back of thisform.
23.Site diagram or additional well details:
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessarq.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below lead surface: rs 00 24a.For AD Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrffereni(emmple-3`@�200,and 2@1ooI coon to the following.
10.Stadc water level below top of casing:_ 7 d (ft) Division of Water Resources,Information Processing Unit,
If water level/s above casing;rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: pn.) 246.For Infection Wells: In addition to sending the form to the address in 24a
IL Well construction method: ,�]j above,also submit one copy of this form within 30 days of completion of well
lie.auger,rotary,-bit,direct push etc.) � - - construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) J Method of test: J%4! P/0 24c.For Water SuoDly&Iniecdon Webs: In addition to sending the form to
p� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type ! Amour O completion Of well construction to the county health department of the county
where constricted.
Form GW-1 North Carolina Departmem of Environmental Quality-Division of Water Resoiaces Revised 2-22-2016