GW1-2022-10754_Well Construction - GW1_20221209

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WELL CONSTRUCTION RECORD(GW-D For Intemal Use Only:
I
L Well Contractor information:
Cameron Bazin 14.w17ERZONEs i
FROM TO DES
CRIPt'tO1V .
Well Contractor Name O!!S IL ft.
4518-A { e. ft.
NCWellContrectorCertifieaionNumbw 15.Oa'LMCASING.farmolticesedweUs OR lieablc
Aqua Drill,Inc. FROM TO DIAMErER'ry 7�CICNESS MATERIAL
(!2ft. �Oo
Company Name 16.DMRCASINGORT)BING therm aldoted-loo
2.Well Construction Permit& � ���� FROM ft ft:TO DIABMTER THICKNESS MATERIAL
List all appllcable well construction permits A e.Ula County.State,Parlance,etc-)
3.Well Use(checkwell use):
Water Supply Weil- FROMTO DratrlETEe SLOT s¢E TRiCKNESS MATERIAL
Agriculturid MunicipaMblic ft.
Geothermal(HeatingtCooling Supply) esrdential Water Supply(single) ft ft.
Industtial(Commercial Residential Water Supply(shared) Ig GRODT
' Irri �oII FROM TO MATERIAL EMBLACF.h�NT METHOD&AMOUNT
Non-water Supply well: $ 2 S
Monitoring
Recovery ft fL
Injection WeU: ft, %
Aquifer Recharge QGloundwaterRemediation 19.SAt+iDlGRAVELPACK d [icable
Qnifer Storage and Recovery Salinity Bawer FROM TO MATERIAL EMPLACEMECIT M61HOD
erTest OStonriwaterDminage ft R
caimental Technology )Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets IF
FROM TO DESCRIPTION color h saWrock R sin
size.et�3
Geod-mal(Heatin CoolingRetum Other( isinunder#21Remarks % 0 ft.
4.Date Wells)Completed: �5 Well 1D# O ft 5 ft
ft ft.
5a.Well Location: "if rz
Facility/OwnerName Facility Wff(ifapplicabie) it ft
U 56 /h ,. 4r. v-, 4-fae~Y ft. IL In,v�for
m.a5aC'n i l,r;l
Physical Address,City,and zip
Sl.REMARKS CFG
ifm e "r , d
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds;or decimal degrees:
(if well field,one lavlong is sufficient) 22.Certification:
6.Is(are)the welts ermanent or EOTemporary
Sigoannc o well oatr.w
By signing this form,I hereby certfy that the wells)ures(were)constructed in acrordance
7.Is this a repair to an existing weft Dyes or e with 15A NCAC 02C.0100 or]SA KCAC 02C.0200 Well Construction Standards and that a
If this is a repair,flit out known well construction inforafatio mud¢zplairs the nature of the copy ofthis rernud her been provided to the nr11 rnvner.
repair under 921 remarlasection or on the back of thisform. 23.Site diagram or additional weft details:
S.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 additional pages ifnecessary.
chilled: SUBMrffAL INSTRUCTIONS
9.Total well depth below land surface: (R) 24a.For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdrfferent(example-3 a@200'and 2@1001 construction to the following:
10.Static water level below top of casing: (fk) Division of Water Resources,Information Processing Unit,
/Rater level is above casin&use 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24h 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
1L Well construction method: I ©�1K Y construction to the following:
(i a auger,rotary,cable,d=ctpwb.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Centex,Raleigb,NC 276991636
13a.Yield(gpm) Method of test: 1t 24c.For Water Supply&Iniection Welts: 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 Amour completion of well construction too the county health department of the county
where constructed.
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Foam GW-I North Carolina Department of F.nviroamental Quality-Division of Water Resources Revised 2-22-2016