GW1-2022-10443_Well Construction - GW1_20221116

Pru Form
W CONSTRUCTION RECORD(GW-11 For Internal Use Only:
ELL
I.Well Contractor Information:
Cameron Bazln 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. R•
4518-A ft. ft
NC Well Contractor Certification Number FROM
OUTER CASINi Ili(foi multi-cased wells)AR LINER rf a h'amble
FROM TO I DIAMETER TffiCIQVESS
Aqua Drill,Inc. It. S ft (p I°•
Company Name 16.LNtNER CASING OR TOEING eothermal closed-loo MATERIAL
TffiCIQJFSS
2.Well Construction Permit#: FROM ft.
DIAMETER. Ic lo.
List all applicable veil catsirvetioa pernzits(Le.UX,County,State.vortance,etc.) in
ft. ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: r•ROM TO DIAMETER SLOT Srzs THICXNFSS `tATERIAt
Agricultural
OMunicipaVPublic ft, ft in
PP y(single)
ft tt in
- Geothermal(Heating/Cooling Supply) Residential Water Supply
ndustriaVCommeroial Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACF YMNT METHOD&AMOUNT
RIrri
ation ft. ft.
Non-Water Supply Weil: ft
Monitoring
Recovery R'
Injection Welt: it. fr.
Aquifer Recharge ©'iGroundwater Remediation 19.SAND/GRAVEL PACK a trcebk
FROM TO MATERIAL EMPLACEM1tEiVT MEMOD
Aquifer Storage and Recovery 0SalinityBarrier ft ft.
Aquifer Test oStonnwater Drainage
ft, tt
Experimental Technology oSubsidence Control
Geothermal(Closed Loop) �tTmcer 20.DRILLING LOG attach additional sheets if neeess
FROM TO DESCRIPTION war,hardn-m S01. ck t q caio z'ac,etc)
Gcothcnnal(I?cdtin�/Coolinr Rctum) Othcr(explain under 421 Remarks) v ft. It's' It
r�n o tt it
4.Date Well(s)Completed: O Z9 i'vR'ell IDR Y e. ft.
5a.Well Location: ]� ft ft.
A l X<<� Val� ft. ft r
Facility/Owner Name J e' Facility lD1,(if applicable) ft• ft. �"lii.,,,� t V
I10o F 0IGY 12( wwok✓ftI 4--, ft- ft
Physical Address,City,and Zip '-
XN(k iih ' )f,l
21.REMARKS `
County Parcel Identification o.(PIN) ifhvr c
5b.Latitude and longitude in degrees/minutes(seconds or decimal degrees: 22 Certification:
(if well field.one ladlong is sufficient) 1012
Signature Certified ell Contractor Date
6.Is(are)the well(s) ermanent or oTemporary
r By slguing this jorn;I hereby certifythat the well(J)was(uxre)constructed in accordance
7.Is this a repair to an existing well: Yes li ..d
No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repah,fill as knovm nzll Coitstrrzcth i,Jyf:. -',fain the natum ofAa
copy of this retard has been provided to the well owner.
repair under k11 remarks section or on file back of this Jo 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
c For Geon,only I T - is n Closed-Loop I GeothermalOTT Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 2 D S (ft-) 24a• For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(erample-3@200•and 2@1001 construction to the following:
1o.Static water level below top of casing: 0 ( ) Division of Water Resources,Information Processing Unit
7
If water level is above casing.use '+"- 1617 Mail Service Center,Raleigh,NC 27699-1617
1I.Borehole diameter. 6 (in•) 24b.For Injection Wells: In addition 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-Well construction method: Coto1 n/ construction to the following
CLe,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
EYield
PPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
�� Method°f test III
24c.For Water SuPRIV&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
type: /Y rl Amount 7+' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016