GW1-2022-09634_Well Construction - GW1_20221021

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WELL CONSTRUCTION]RECORD(GW 1) For Intemal Use Only:
L Well Contractor Information: l
Cameron Bazin 14:waTEltzoNEs�.- � ;::'i••�-: ��.:..•. ::.: :-
:........:.::.. . ..
Well ContractorName FROM TO DESCRTMON
�s-A 13 ". ft. 25 Ainn
ft. ft
t
NCWellConhactorCer fiwfionNumbcr 15:OUTER.CASING`formulif-rased•1ve OIiLTNEIt ifa Iicalrle' :'•: •'•`::
Aqua Dill,Inc. FROhf TO DIAMETER TDICIOQFSS MATERIAL
O ft. U � it to G
Company Name
/� p -I6.INNERCASING'ORT'E1BING othermalctosed-16 ..
2.Well ConstructionPermit#: ' ( 75-0 S FROM TO DIAME'TLR THICIQQFSS MATT RfAi'
List all applicable nzll castructton permits(ca VI,County,Slate,Yariaam eta) ft ft
3.WellUse(checkwell.use): D• D• in.
Water Supply Well: 17.SCREEN':•. :
_ EROM TO DIAMETER SLOT SIZE
,. tnlC[Q�fESS MATERlA1,
Agricaltaral lAnnicipal/Poblic H: it in.
Geothermal(Aeating(Ccoling Supply) (I 'Residential Water Supply(single) M ft in.
IndushiaUCommercial DResidential Water Supply(shared)
•18.GROUT•"..
W ation FROM TO KATMAI, I EtVJPLAi Nr MMOD&AMOUNT
Non-Water Supply Well: ft. M
Monitoring ORecovery D. ft
1-Geothermal
tion Well: g• ft
uiferRecharge DGroundwaterRemediation
19 SAND/GRAVELPAOC ifa Ticableuifer Storage and Recovery OSalmityBanier FROM To MATFRIAL EIVIPLACEhfEN-h=0Duifer Test tOStomnwaterDrainage ft. 3tperimental Technology I_ Subsidence Control & ftothermal(ClosedLoop) OTrdcer 20:DRILLIPIGLUG atmchadditienatsbeetsifucmm(Heating/CoolingRetum) FjOthcr(explain under#21Remar'da) EV M TO DESCRIMONtcaror,bmtirs,svithoek type,grizinsimetn)
n ft. ft
4.Date Well(s)Completed: G� 2 ZZ Weil IDR (.So R• s ir,
it I
5a.Well Location: ft. r
Facilltylo%—Nanj
r 1 Facility lD2(ifeppGdxhle) %
ISO LOX 7(bf 1-n I'hoGint/r�f([: tt, ft
804ir4 UM
Physical.
/^Address,City,and Zip R tt (into�ntaeon Pr+rC
11a� 21.REIYL4M
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(fwell field,one ladlong is sufficient) 22.Certification:
Y,2 N 80•42835 W
2
6.IS(are)the weil(s) :.. ermanent or iDTemporary Signature aFCerfified Well Contractor Date
By signing this form,I hereby certify Char the,ivell(s)was(were)constructed in accordance
7.Is this a reps' to an existing wen: E3Ycs or, No with ISA NCAC 02C.0100 or I5ANCAC 02C.0200 Pell Construction Standards and that a.
Iftlris is a repair,fill outkrrona well co+rsfnrcAon injarrna0 jj+anddd explain the ruihve ofthe copy ofthis ircaid has been provtdrd to the well olvner
repair under#21 r einarks section or on Ore back of thisfarm. 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
Youmay also attach additional page
construction,only 1 GW:1 is needed_Indicate TOTALNUMBER of wells construction details: s if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
For mulaptervp&Est arldepthsifd$erent(orample-3@200•and 2Qn1001 construction to the following:
10.Static water level below top of casing: y 10 (AL) Division of Water Resources;Information Processing Unit,
Ifwaterlevel is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. JO rn.
( ) 246.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of wall
12.Well wnstrnetlon method: CO�a�y construction to she following ±r
(i.e.auger,rotary;cable,dir-tp-li,rtd)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centee 4,Raleigb NC 27699-1636
13a.Yield(gpm) Method of test: Sf 24a For Water Sunnly&Infection Wells: In addition to sending the fomr to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:�,�7i• completion of well construction to the 1county health department of the county
where---tructe L
Form GW-1 North Carolina Department of Envimnmcutal Quality-Division of Water Resources Revised 2-22-2016