GW1-2022-10753_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD(GW-1) For intemal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.wATt�tZONES
7;f To DFSCRD'tION
Wc11 Contractor Name ft4518-A tl. fL
NC Well Contractor CertifieationNumber MOUTERCASING.for multi-used wells OR LINTER da Gcable
Aqua Drill,Inc. PROM To DIAMEI'ERin TmClavEss MA
TEML
O /Oo
CompanyName e 16.EMR CASING OR TUBING thermal Bored
-too
2.Well Construction Per ft# 1 7 J Z FROM 1 To TatcrQtsss fn. MATERUL
List all applicable welt construction peamits(i e.UIC Giant};Stag Variant etc)
& f,L is
3.Well Use(check well use):
Water Supply Well: FROMS 17. TI To DIAMETER Isum$ME THICKNESS 11 MATERIAL
Agricultural OMumicipaUPublic fL it.
Geothermal(HeatiDg/Cooling Supply) essential water supply(single) ff m
1ndustrial1Commeroial E lResid-fial Water Supply(shared) 1&GROAT
i Ilri 'oa FROM I TO MATSRGL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O & 2 S
Monitoring 13Row R R
Injection Well: R. %
Aquifer Recharge OGtonadwater Remediation 19.SAND/GRAVELapplicshie
quifer Storage and Recovery OSalinity Bawer FROMTO MATERIAL PMPLACEMEhT METHOD
OD
OStoffi ewaterDrainag IL
MEVarimental Technology OSubsidence Control R. tt
Geothemual(Closed Loop) OTraoer 20.DRELLI NG LOG attach additional sheets if
ERO51 TO DHSCRIPrION eolar tr soluroek n stm eta.
gGeothemislTeatin Cooling Return Other( lainunder#21Rtmladts 0 R 1 0
4.Date Wells)Completed:_t15_ 2 Well ID# oft Sit
B. ft.
5aRIAcation: _ -
l���•�GQ_ ft. fr. 5 s
0 ,r
Facility/OwnerNae Facility W#(ifapplicable) ft. ft.
m _
3t 5C �t�+ v � Cca .1� rL
Physical C' andZtp � K tt Inycr�i��� ' ;c.�Or::S
ys Address, ay,
21.REMARKS
County Parcel Ideni ficationNo.(PIN)
5b.Latitude and longitude in degreestmiautestseconds or decimal degrees:
(ifwcll field,one Wong is sufficient) 2L Certification:
3S. Bd�oG N31, t632o w '/L�/ 1- 7
6.Is(am)the well ermaneat or 01rerriporary signaturc o 6ed weII tractor
By signing this form,I hereby ca%O,that the xell(s)ass(Were)constructed in accordance
7.Is this a repair to an existing well tOYes orN% with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standard*and that a
If this is a repair,Jill out known well construction inforamtio and explain the nature of the copy ofthis record has been provided to'dw nil!mvner.
repair under#21 rrmartla section or on the back ofthisform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.Yon may also attach additional pages ifnecessary.
drffle&- SUBNMAL INSTRIICTIONS'
9.Total well depth below land surface: 2--v 00 24a.]For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ffdifjerent(example-3 a@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (fL.) Division of Water Resources,Information Processing Unit,
Ifsaser level is above casing.use"+'j 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diametei.. (in) 24b.For Iniection 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
=Well construction method: construction to the following.
(l ange,rotary,cable,du—push,etc.) JF
Division of Water Resonrces,tndergroand Infection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 276991636
13a.Yield(gpm)_ Method of test: 24c-For Water Suauly&Infection Wells: In addition to sending the form to
the address(m) above also snbrnd'one copy of this fort within 30 days of
13b.Disinfection type: Amount completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Eovironmemal Quality-Division of Water Resources Revised 2-22-2016