GW1-2022-09924_Well Construction - GW1_20221031

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WELL CONSTRUCTION RECORD trGW 1) For Intemal Use Only:
I.Well Contractor Information:
Cameron Bazin
-14:.WATER'ZONES.
Well Contractor Name FROM TO I DESCRIPTION
4518-A ZZSft. L o n.
ft, ft
NC Well ContractorCertification Number
15.OUTER.CASDVG formulfi-cased'ivclls ORL'INER rfa Iirmtile •'.:`;
Aqua Drill,Inc. FROM T DIAMErER TTnCtrNEss CERIAt
Company Name
2.Well Construction Permit#• ? 1 FROM, ER CASING'OR TIDING eotbermolclased-Ida
FROM M I DIAMETER I 1'<DCEQQESS MATERIAL
LIU all applicable ivellcomimciianperwitrTLe. County,State,irarimm ew-) ff. ft. fu.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN':
FROM TO DIAMETER SLOTSt2.T, T1tICKNESS DtATEIiIAl,
Agricultural Municipal/Public ft. R. in.
Geothermal(Heatmg/Cooling Supply) Residential Water Supply(single) fc ft. to.
Industrial/Commercial DResidential Water Supply(shared) . 18.GROUT-
Irripation FROM TO MATERL41, EMPLACEMENTMETROD&AMOUNT
M
Non-Water Supply Well: O ft ft li�
Monitoring ORecovery M M
lGeothennal
jection Well: R IL
Aquifer RechargeDGroundwaterRemediation19.SAND/GRAVEL PACK tfa rieable Aquifer Storage and Recovery OSalinityBanier FROM To MATERIAL EMMACPAMNTMET90D
AquiferTest DStormwaterDrainao ft. ft.
Experimental Technology Subsidence Control ft. ftGeothet7Da1(Closed Loop) ®ITrarxr 20:DRILLING LUG attach additional cheats if n(Heating/CoolingReturn) ;-')-' Othcr lain under#21 Remarks) RO ft. TOR DESCRIMON Wor, a dro bnrdns,soreh t a rain she,etc)
4.Date Wells)Completed: i� Well ID# 7 5 fL 2 ft AQ-, h-
5a.Well Location: t ft' M
4h65 4Inel_�C- ft. it. 1-7r N
®
Facility/Owner Name FacilirylDo(ifeppGwble) fL M
f' V a.,D
lea(dh GrkAme, (a Mot✓�cSrr/ ft f� 202.
1
Physical Address, ity,and Zip fL fZ
�fiG 21.REMA121CS ` ufid}
County Parecl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(f well field,one lattlong is sufficient) 22.Cer h rication:
6.Is(are)thewell(s) 7permanent or Temporary Signature of Certified Well Contractor Dater
By signing this form,I hereby certify that the rvell(s)was(rsere)consbucted in accordance
7.Is this a repair to an existing well: E3Yes or ON. with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 fl ell Constriction Standards and that a
Ifdds is a repau•,fill out/Moan mall emtsowcdnn infannd1 and erplahi the natrve ofthe copy ofthis record has been provided to the well owner.
repair-under#21 ramar/a section or on die back-of thisform
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled: t� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z ys (ft) 24a.For Ali Wells: Submit this form within 30 days of completion of well
For multiple wefts list all depths ifdi erent(example-3@200 construction to the following
10.Static water level below top of casing: y4:2 00 Division of Water Resources,Information Processing Unit,
If water level is above casing,use'+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_J(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 02�tn�I�
,, �T above,also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,daeetpush,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: Q0/ 24c.For Water SunDlv-&Iniectlon Wells: In addition to sending the form to
�7 the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Eavimnmcutal Quality-Division of Watcr Rcsomces Revised 2-22-2016