GW1-2022-10199_Well Construction - GW1_20221111

WELL CONSTRUCTION RECORD(GW-1) For Intern Use al Only: r_m
1.Well Contractor information: i
u
Cameron Bazin 14.WATER ZONES'..
Well CoutraetorName PROM TO I DESCRrMON
4518 A JAL Z S
ft. ft.
NC Well ContrWor Certification Number
15.OUTER.CASIlYG'(for mul*eased-Wells ORLIl�R tfa' 6cebte
Aqua Drill,Inc. FROat To DIAMETER THICtavEss MATERIAL
Company Name 0
ft. I go fL In.
/1 -16.INNER C NG OR TIIBING(geothermal cloied-16bal
2.Well Construction Permit#: (s � 0 FROMIft
TO DIAMETER THICKNESS MATERIAL
List all applleable Kell constrvotfon permits(L&UIC,County State arlartm etc.)3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN':'
FROM TO DIAMTER SLOTS= THICKNM MATERIAL
Agricultural DMunicipaMblic ft it, in.
Geothermal(Heating/Cooling Supply)residential Water Supply(single) & ft. ia.
Industrial/Commetoial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft, 2 S ,fL
Monitoring DRecovery ft• ft,
injcctian Welt:
ft
Aquifer Recharge oGroundwaterRemediation ft.
Aquifer Storage and Recovery Saliai Barrier 19.SAND/GRAVEL PACK ifs livable .
tY FROM TO I MATERIAL I EMPLACEMENr METHOD
Aquifer Test [3Stormwater-Drainage ft. ft.
Etcperimental Technology DSubsidence Control
Geothermal(Closed Loop) DTracer 20:DRILL]NGLOG attach additional sheets'ifnecema
Geothermal(Heating(Coolin g Return) nOthcr "plain under d21 Remarks FROM I TO IDESCRlPi70N eotor,eardnm%sauvocke a min sac,eiZ
ft. C ft.
4.Date Well(s)Completed., 7 ZZ Well ID: 7 R tic
Sa.Well Location: ft
�Jtirt ow,//f ft: MMULIVED
Facility/OwnerNaine Facility ID#((if applicable.) ff' ft
r�ldSr L ow�e� & 1ft.
Physical Address,City,and Zip z ft. ft �. P17=
506irm Ur
5�f1j y 21.REMARICS
County Patcet Identifiearion No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: i
(i£well field.one lat/long is sufficient) 22.Certification: i
35, S2290 N &. S6-27123 w
6.Is(are)the wells) .: ermaneut or DTemporary Signature of Certified Well Contractor Dat
By signing this forn,I hereby certify That the wells)sm fuse)constructed in accordance
7.Is this a reps' to an existing well: Dyes or ONO lath 13A NCAC 02C.0100 or 15A NCAC 02C.0260 Well Constriction Standards and that a
If tlds Is a repair,fell out/atones well constniction i4ronnadon ad exp/ahl the natio a of the copy ofthis record has been provided to the well owner
repair under 921 retnarkr section or on the bad-of thtsform.
23.Site diagram or additional well details:
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 i GW-1 is needed Indicate TOTALNUM 3ER of wells construction details. You may also attach additional pages if necessary.
drilled
D SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 1 a s (ft) 24a.For All Wells: Submit this form within 30 days of c For muUiple wells&I all depths jdigerent(erainple-33@200'and 2Q100� construction to the following: completion of well
10.Static water level below tap of rasing: • M) Division of Water Resources,Information Processing Unit,
I11.Borater e o e di am ter.. 7LTG +•/� 1617 AM Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ('� /+(in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method (( Q7�Oil� above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direetpush,etc.) construction to the following.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm)_ Method of test: % r 24c.For Water SunDly&Infection 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 o2 1 completion of well constriction to the county health department of the county
where constructed
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of WaterResourcm Revised 2-22 2016