GW1-2022-10194_Well Construction - GW1_20221111

PrintForm..
WELL CONSTRUCTION RECORD(GW 1) For Intemal Use Only:
I.Well Contractor Information:
i
Cameron Bazin
14:WATER zoN�s- -
Well Contractor Name FROM TO I DESCRIPTION
4518-A 1002 ft ft
ft. ftNC Well Contractor CertificationNumber 15.OUTER.CASING formuld-casid-wells ORLVWR Lief lieable
Aqua Drill, Inc. FROM TO DMMUER THICKNESS MATERIAL
0 it 115. ft / in. {/�
Company Name (/ v
n Q 46.INNER CASING'OR TIIBING. 'thermal doted-loa
2.Well Construction Permit#: y 9J FROM To Diatom I 1ffiCKNESS Metsarer.
List all appllcabie well construction permits ii a UIC,County,State.Vari 4=ere) n ft Ia.
3.Well Use(check well use): ft ft. In.
Water Supply Well: 17.SCREEN':
A cultural FROM TO DIAMMR SLOTSMS THICKNESS MATERIAL
6'a I Municipal/Public g, it in.
Geothermal(Reating(Coofing Supply) residential Water Supply(single) ft It in.
IndustriaVCommercial Residential Water Supply(shared) 1&GROUP
Mization FROM I To MATERraL EMrLACEMENTMLMOD&AMOUNT
Non-Water Supply Well: Q ft. .&
Monitoring ORecovcry R. %
Injection Well:
it it
qutfer Recbarge oGroundwaterRemediation
19.SAND/GRAVEL PACK rf lfcable .
'
3Aquifer Storage and Recovery oSalinityBartier FROM To MATERIAL EMPLACEMENTMEMOD
:)Aquifer Test CIStotmwaterDrainage ft. ft
-Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG attach addifienalE sheets'if ao
Geothermal(Heating(Cooling Return) Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color.hardnem sni0rock qpe,gmia she,eta)
// 49 ft. 0 ft S
4.Date Well(s)Completed: 1� 'ell]Dm R. ys ft
5a.Well Location: ) r ft.
�Qh/l N')I�S ft ft
Facifity/Owner Name Facility M#(ifapplicable) ft, h
157 krs,Ia► it ft
Physical Address,City,aA Z it. ftNUV I I Z
S�PN 21.REMARKS
County Patrel Identification No.(PIN) Ift¢Oflxla:t n f f:>:909Jt'�Uf1
5b.Latitude and longitude in degrees/minutes/secands or decimal degrees:
(if well field.one]at!long is sufficient)
22.Ccltfication:
1. you yo N $o- S` ZZ'; W _
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Connaaar Date
By signing this form,I hereby rertiify that the rvell(s)was t1twe)constructed in accordance
7.Is this a repair o an c.sting well: [3Yts or _ No wi&15A NCAC 02C.0100 or 1SA NCAC 02C.0100 Well Construction Standards and that a
/fthis is a repab:fillout known n211 construcfion inform n and ezplaiu tile nature of the copy oflhis record has hem provided to the ivell owner.
repair under 01 remarks section or an the back of this form
23.Site diagram or additional well deta17s:
8.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 additionalpages if necessary.
drilled:
SUBMITTAL INSTRQCTIONS
9.Total well depth below land surface: 226 (fW 24a.For All Wells: Submit this form within 30 days of completion of well
For mulhple wells Ist ay depths ifdigerent(example-3C@200'and 2(3a 100) construction to the following:
10.Static water level below top of casing: 7 10 (ft) Division of Water Resources,Information Processing Unit,
1f uWcrlevel is above casing,use"+' 1617 Mall Service Ceutcr,Raleigh,NC 27699-1617
11.Borehole diameter. ow _(on.) 24b.For Iniection Wells: In additions to sending the form to the address in 24a
above also submit one copy of this form within 30 days of completion of well
12.Wei!construction method —�V construction to the following
(.e.auger,rotary,cable,d'nactpush,Mc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) 0 Method of test: f�A r- _ 24c.For Water SunDlv-&Iniection Wells: In addition to sending the form to
the address(es) above, also submit ohe'copy of this form within 30 days of
13b.Disinfection type: Amount: �Oy completion of well construction to the county health department of the county
where contracted.
Form trW-1 Noah Carolina Department of Environmental Quality-Division of Water Resounm Revised 2-22.2016