GW1-2022-10192_Well Construction - GW1_20221111

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WELL CONSTR UCTION CO
RE
RD G -1 For Internal Use Only:
1•Well Contractor Information: 14.WATER'ZONES'. DESCRIPIION I
Cameron BazJn FROM TO ft.
ft•
Well Contractor Name 0ft.
ft.
45`1$-A e wells:OR it
ormu ti c aIiERIAt
Is.OU1ER.CASIIdG los'd'
D MA
NC Won contractor CuficanonNumber FLtOM TO
n In.
d
AQua Drill,Inc. fp iberm+ c►IC
16.INNERCAS7NG'OR'TDBINGR •f�ctavrss
Company Name /1 O FROM TO in.
it, a tt rc
2,Well Construction Permit# uary,Smte variance e(c.)
List ail applicable tudl construction permits Ae.U1C, ft. ft.
3.Well Use(check well use): 17.SCREEN: DIAMETER scor sty TFUC34HFss MATERIAL
i Well: FROM TO
Water Supp Y ft. ft
in
Agricultural �MunicipaVPublic
Geothermal(HeatinglCooling Supply) Residential Water Supply(single) ft
io.
t;Residential Water Supply(shared) IS-GROUT MA PE[trAr. EMpLACpN1ENT METROn&AMOUNT
IndustriallCommercial FROM TO
Irri ation tQ ft. 25 'ft. 0
.ion-Water SuPplby Well: ft, ft
Monitoring Recovery
ft: ft.
Injection Well:
' �
Aquifer Recharge Gm ly
undwater Remediation ,S IGRAVEL PACK tf a ueable . �LACEM�yTMEfBOD
FROM TO MATERIAL
- Agaifar@tvrn8oandRuaeroerY �Sol6tityBartier
Aquifer Test []Stormwater Drainage ft
ft.
Experimental Technology Subsidence Control
Tracer 20.DRI1T.ING*G attachDddi�Co r$ONe(color•noraa miltrackt r Mtn simdm
Geothermal(Closed Loop) � FROM To
Geothermal(HeatinglCoo' Reutm)
Other(cat lainunder#21Remarks) ft. ft-
ft. ft
4.Date Well(s)Completed: (� ��a m'" fL r
5a.Well Location: ft. ft
FacrGty/Owner Name facility 1DR Cif applicable) fc
t ft.
"id,is �41 , Y kw�1Y�_ ft. ft �fl(OfiRaJ3S1 Pf: a1h"�L)fli.
of
Physical Address,City,and Zip 21.REMARKS
CountyT j parcel rdentification No.(PIN)
5b.Latitude and longitude in d eeslminutes/seconds or decimal degrees: 21 Certifica'on:
(ifwell field,ant]atllong is sufficient).
. 67 8 w IG
Date
Sipature of Certified Well Contractor
"t tern that(the tvell(s)loos(were)constructed M accordance
6.Is(are)the well( permaricnt or �iTemporary By sig5A this f02C 100 Or
7y
.vide ISA NCAC OIC-0100 or ISA NCAC 02C AZ00 Well Construction Standards and that a
= 7.Is this a repair to as existing wcD: 4QYis or Ho CON of this rrxard lras been provided to the tveil owner.
#'this is a repair,fit]out knmtv3 tveH constrnctian iaf°nn?a and explain the nature of the 23.Site diagram or additional well details:
t repair under#21 remarks section or on the back of(iris(
You may use the back of this page to provide additional we{I site details or w
ell
8. s having
the same
construction details_You may also attach additional pages if necessary.
For Geoprobe/DPT or Closed-Loop Geothermal Well
" construction,only 1 GW-1 is needed. Indicate TOTALUMBER of wells
PI SUBMITTAL INSTRUCTIONS
drilled: completion of well
9.Total well depth below land surface: 12.5 (ft) 24a.For All_Wells: Submit this fay 30 days of
For multiple tvet]s Her all depths ifd yrerent(example-3@200'and 2@100� construction to the following
10.Static water level below top of casing: y0 (ft) Division of Water Resources,Information N Processing
Unit,
1617 Mail Service Center,RaIei=6+
ffivuerki,d is abovecasing.use-+" the form to the address in 24a
11.Borehole diameter. —fin) 24b.For Infection Wells. addition to sending of letton of well
e,abov also submit one co of this form within 30 days comp
/�• -� construction to the following:
Ct Well construction method: oandln'ecfion Control Program,
C•e auger,mom'•cable.direct Push,ems) Division of Wales Resources,UD�ergr J
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Cen7r,Raleigh,NC Z7699-1636
24c.For Water Sunni,&,InieMion Wells: In addition to sending the form to
i3a.Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
,,� completion of well construction to the county health department Of the count'
13b.Disinfection type: _KJL___ Amount: where constractod-
Form GW-1 North Carolina.Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016