GW1-2022-10166_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW 1) For Internal US e Only:
I.Well Contractor information:
Cameron Bazin 14 ..wATERZONFS`
Well Contractor Name FROM TO DESCRIPTION
4518 A S er rt O
NC Well Contractor Certitication Number
NOV 1 0 2022 ft' ft
15:OUTER.CASING formulfi cased wells ORLQ(ER da limlile'•'_:'; ':..
Aqua Drill,Inc. FitOM TO DIAMETER TmclavEss MATERIAL
Ifltoftrlatioll Pracseair►o Unit O ft. � ;�
Company Name
�7) -16.DMR CASING"ORTI7BING. ieuffiermalclosed-lo
Z Well Construction Permit 0: r FROM I To I DIAMETER I TFULV Fss I atWMWR I '
List all applicable well construction permits(r.e.L7C Convey,Store.FarlaneG etc) ft. ft lo.
3.Well Use(check well use): ft. ft. ;n.
Water Supply Well: 17.SCREEN':
FROM TO DIAMETER SLOTSIM THICKNESS MATERIAL,
Agricultural oMunicipalRublic fG ft in,
Geothermal(Heating/Cooling Supply) �2� esideritral Water Supply(single) R & in.
- Industrial/Commercial DResidential Water Supply(shared)
I&GROUT
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: rt ft G
Monitoring ORecovery ft. &
Injection Well:
Aquifer Recharge ft' ft q urge �IGmimdwaterRemediation
Aquifer Storage and Recovery Salim Barrier I9.SAND/GRAVEL PAGE n Ticabte .
__ FROM TO PL MATERIAL EMACE14 wHiEmori
Aquifer Test [)StormwaterDrainage ft ft
Experimental Technology OSubsidence Control ft. ft
BGeothermal(Closed Loop) ®)Tracer 20.DRILLING LOG attach additional sheets-ifnecess
Geothermal(Heating(Coolin Amon) F10ther(explain under#21 Remarks) FRoM To DESCRIPTION(eotar,bmdness,svtUmek in see,eta
/ ft � ft
4.Date Well(s)Completed: I 0 Z C- well)Dd ft. �8 ft
5a.Well Location: Crnr- H u.-'-S ft ft.
�fawks & ft
Fkality/owrifflAlarne FaciliryID#(if applicable) ft. It
19 o .- �.� t'tio kcal'/� t.
Physical Address,City;and Zip ft ft
�/, t/y� 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladling is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or OTemporary Siena-aue ofCeni ad Well Contractor pare
By slgning this form,111-eby certify that the 1ve11(s)tuns(eae)constructed in accordance
7.U this a repair to an existing well: E3Ycs or - 0 with ISA NCAC 02C.0100 or ISA NCAC'02C.0200 Well Constraaion Standards and data
If this it a repots ft0 out known wdi ronstnic ion informat' annd-explain the nature ofthe copy oft his nrcord has been provldedto the iue/l envner.
repair corder d21 renrarlanc ion or-'an the back of thisfornt
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 TOTALNUMBER of wells construction details. You may also attach additional pages if necessary.
dulled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /8 S 24a.For All Wellr. Submit this form within 30 days of For mufa le wells list aA (R) y completion of well
p depths ifdi,�erent(example-3Q200'and2Q100) construction to the following.
fiv Static water level below top of casing: y� A) Division of Water Resources,Information Processing Unit,
IJivater level ls above casing,use+' $
1617 Mail Service Center,Raleigh,NC 2709-1617
Il.Borehole diameter. 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 four within 30 days of completion of well
(i.e.auge,rotary,cable,direct push,ctc.) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
c 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) So Method of test: !t' k 24c.For Water Sunolv-&Iniectioti 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:--tr" �-- completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resoutees Revised 2-22-2016