GW1-2022-09233_Well Construction - GW1_20221003

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WELL CONSMUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Cameron Bazin 14 wATERZONEs i.
WO[CotnractorName FRODf TO DESCRIPTION
4518-A S ft fL
ft. ft
NCWeI]CordractorCettificationNumber
15.OUTER CASING(for mnitirasod wells)OR LINER rda ficable
Aqua Ddll,Inc. FROM TO DUNK= I TIOCKNFM MATERIAL
Company Name
16.INNER CASING OR TUBING thermaldosed400
2.Well CODStrnetiOII permit : ?�tj O FROM I TO DIAMETER THICKNESS MATFRiAL
List allappllcable well construction permits(i.a.U1C,County,State;Yarlance,etc) ft. ft in.
3.Well Use(checkwell use): ft ft in.
ElZu.stfinal/Commemial
upply Well: 17.SCREEN
FROM TO DIAMETER SLOTSrM TEriCK1VFSS MATERIAL
MunicipaliPubticermal(Fleating/Coonag supply) Residential Water Supply(single) tit Residential water supply(shyion 19.GROUT
F'ROlti TO MATERIAL EMPLACEMM METHOD&AMOUNT
Non-Water Supply WeD: v ft, 27
�
Monitoring _-Recovery ft
Injection Well:
' � �in Recharge Groundwater Remediation fer ft
Storage and Recovery Salinity Barrier FROaSAND/ I TO PACK
JAqquifer
MATERIALe I EMPLACEMENT METHOD
Aquifer Test [3StDrmwater Drainage ft fL
Experimental Technology Subsidence Control & &
Geothermal(Closed Loop) Traces 20.1) IT-1 ING LOG attach additional sheets if
Geothermal(Pleating/COoling Return) MOther( lain uuder#21 Remarks FRON1 TO DESCRIPTION color,B somumrk& mm grain size etc
/���., ft
4.Date Well(s)Completed: Well 1Df# 100 R•
Sa.Well Location,:: tit ft Qom.
•-� �—•
Facility/ Name/ Facility W9(if applliiccable) ft ft ni ,' S/
�X lu�S ��V(li i �i/l art 6 f&
Physical Address,City,and Zip f L ft ft 77 - 'tt-:�, tt",
1 i_
Wdw, 21.
County PaaxlIdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,cme lat/long is sufficient) 22.Certification:
3S. 74062. N _ SD. 5?l 9�/ w
6.I ere)the we"(1-p"ermanent or DTemporary Sm ofCerofied Well Contractor ate
//�� B}1 signing this form,I hereby ceray5,that the well(s)was{were)constructed in accordance
7.Is this a repair to an existing well: (Dyes or
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifdds is a repair,fill out known well construction informa!'n and explain the nature afthe copy ofthis rrcttrd has been provided to cite xr!l owner
repair under 1i21 remarks section or on the backofthisjorm.
23.Site diagram or additional well details-.
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 I GW-1 is needed. Indicate TOTAL NUMBER of wells censtniction details.You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 For multiple rvellr list all depths lfdffernnt(¢sample-3Q200 (fL) 249.For Ail Wells: Submit this form within 30 days of completion of well
'and 2Q100�
constriction to the following:
10.Static water level below top of casiug: UP Division of Water Resources,Information Processing Unit,
Jjtwter level ti above casing use"+ 1617 Ma31 Service Centel,Italelgb,NC 27699-16I7
11.Borehole diameter. (in,)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i e.anger,rotary.cable,dhect pusb.etc.) s construction to the following: '..
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center`,Raleigh,NC 276994636
13a.Yield(gpm)__5 _ Method of test: 24c.For Water Sawly&Infection Wells: In addition to sending the form to
13b.Disinfection the address(es)above, also submit one copy of this form within 30 days of
- Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Emvironmenml Quality-Division of Water Resmaces
Revised 2-22-2016