GW1-2022-09231_Well Construction - GW1_20221003

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WELL CONSTRUCTION RECORD L(W--1) For Internal Use O . _
1.Wen Contractor information: j
Cameron Bazin 14.WATER ZONES
WcllContaactorName FROM TO DESCRIPTION
4518-A 2(s ft. "
NC Wetl ContractorCatificationNumber Ft. ft.
15.OIITER CASING for mull-cased'wells OR LINER a licab)c
Aqua Drill,Inc. FROM To D1ntv�rER T7rrtxavass MAT1�tIAL
CompenyName Q 0 � I�
2.Well Construction Permit# 2 • 16.INNERCASINGOR7OBING thermal dosed-too
O/O FROM TO DIAMETER I THICKNESS I MATERIAL
Lfst aU applicable wR11 cotrstruction permits tr.a UIC,Co7vity State,Yarrancw e!a) ft. fL in.
3.Well Use(cheek well use): ft, & in
FAgnricultuml
y Wen: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TRICKNESS MATERIAL
13MunicipaWablic R it. in.
(Reating/Cooling Supply) entied Water Supply(single) iL in
ommen ial ential Water Supply(shared)
IL GROUT
FROaf To MATERIAL Emn ACEmNT bwrHoD tr AMOUNT
Non-Water Supply Wen: ft. a0 fL CQ►`,,�G
Monitoring • Recovery R R
lGeothernual
jection Well:
Aquifer Recharge
oGmtmdwater Remediation
Aquifer Storage and Recovery S g�y� R.SAND/GRAVEL PACK rf (arable
ty FROat TO MATERIAL EMPLACEMENT METHOD
AquiferTest OStormaterDrainage & fL
Experimental Technology E)Subsidence Control ft. itGeothermal(Closed Loop) ftaaxr 20.DRILLING LOG rattacit add'dional sheets ifn eatin Cooling Return) Other(ex lain under#21 Remarks) FROM To DEscRmrlON rotor.tria ram soNroek Srda slat,err
& tL
4.Date Wen(s)Completed: �2 Tit Well ID# ga
t1 S 1L
Sa.Well Location:
LlajZ ft
Facility/Own rName Facility iD6(ifappliwble)v 22
Physical Address,Crty,and Zip ft.
it
2L REMARKS
County Parcel IdeutificationNo.(PIN)
5b.Latitude and longitude in degrees/mloutes/seconds or decimal degrees:
(ifwell ficld,one lavlong is sufficient) 22.Certification:
IT W.c2 N - do. 571 1 -
6.Is(are)the well(s) ermaneat or [(Temporary Srgaa ofCertified Well Contractor Da e
By signing this faun,I hereby occur}'drat the rvell(s)scar(here)cmulnicted in accordance
7.Is this a repair to an existing well: I)Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weff ComPuction Standards and that a
Ifthis it a repair,fit od Im0"n rveR conshucdan informs and explain the nature ofthe cepY ofthis record has been provided to the well olvaer.
repair under 921 r&7xv a section or on the back ofdrlsfonn.
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 damns• Yon may also attach additional pages ifnecessary.
drilled:
5,05 SUB14II1TAL INSTRUCTIONS
F Total well depth below laud a surface: (fL) 24a For All Wells: Submit this form withm 30 days of completion of well
For mulgple wells list all depdrs ffdafferent(example-1(a)Z00'and IQI00�
construction to the following:
10.Static water Ievel below top of casing: O
6
If water level is above casing,use.,,. UP Division of Water ResourcM Information Processing Unit,
H.Borehole diameter 1617 Mall Service Center,Raleigh,NC 27699-1617
(ia)
24b.For Iniection Wells: in addition to sending the form to the address in 24a
12.Well construction method: ! Q�G(��� above,also submit one copy of this form within 30 days of completion of well
0-rage,rotary,cable,direct paste,etc-) Construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
// 1636 Mar Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test W'Rdq— 24c.For Water SuoDly&Iniedion 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: Amount: O completion of well construction to the county health department of the county
where constructed.
FomaGW-( North Carolina Department of SavirOnmenml Quality-Division of Water Resources
Revised 2-22-2016