GW1-2022-10755_Well Construction - GW1_20221209

i
-Or Int Form
WELL CONSTRUCTION RECORD(GW4) For Tntemal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
FROM To DESCRIPTION
Well Contractor Name
4518-A i� It.
NCWell Contractor CertificationNumber 15.OUTER CASING(for m-cesed wells)ORLDUM rif anoIIeeble
Aqua Drill,Inc. FROM To DIAatErER Tllclavtx5 MATERIAL
O 161 1 gG
CompanyName 16.INNER CASING OR TDBING( ealhermal elandel
2.Well Construction Permit : FROM I 0 DLVM TER THICKNESS MATERIAL
fL
List aU applicable well construction permits(e.UIC Caunly.State,Variance,etc)
3.Well Use(check well use): ft. fL in.
Water Supply Well: 17.SCREEN
PP FROM TO I DiAMS ER I SWTSt2E I TmCKNESS I MATERIAL
cultural OMtuicipal/Pabfic ft. R
Geothermal(Heating/Cooiing Supply) dential Water Supply(smP1e) @. fL in.
lndustrial/Commercial Residential Water Supply(shared) 1&GROUT
—1irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Wen: 0 % 37 fL
Monitoring Recovery fL %
Injection Well: R ft.
Aquifer Recharge E3GroandwataRemediation
kG�U.tfhertnal
ifer Storage and Recovery Salinity Barrier FROM TO
PACK 1t IAAie EMPLACEMENT METHOD
Test OSto>mwaterDrainage & &
eaimental Technology E)Snbsidence Control ih �hermal(Closed Loop) E]Traatr 20.DRILLING LOG attach additional sheets ifTo(lea' Coot'tng Retum Other( lain under#21 Remarks) FROM R c ft DEscRleTron color, soalroetc size ere
o c/o •r►ti
4.DateWell(s)Completed: j)3 We➢U)# 10 R' 30S fL
ft tl:
5a.Well Location:
ft. fL
Facility/OwnerName FaeBityID#(if applicable) R ft ' a' i`V
/4e,j;c 1 Ae ~j— fL f3(59�
Physical Address,City,and Tap R
�a, r 2LREMARKS _-
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) y 22.Certification:
rj 5. to 8 7 m �• rGY�y W
6.IS(am)the we➢(O ermanent or QlTemporary Sigoatuc- of Certified Wall Contractor Da
Q BY signing this form,I hereby oerNf•that the weff(s)Ins(were)constructed in accordance
7.Is this a repair to an existing well- I�Yes or _ o with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 llrell Construction Standards and that a
Ifthis is a repair fill out known well conduction f formatro and erplain the nature of the copy ofthlr record has beenprovided to the xeU owner.
repair under#21 r ararins section or on the back offlusf
23.Site diagram or additional well demilc
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
constnrction,only 1 GW-1 is needed_ Indicate TOTAL NUMBER of wells construction dcudlL You may also'attach additional pages ifnecessary.
drilled: SUS II AL INSTRUCTIONS
9.Total welldepth below land surface: 36 (IL) 24a.For All Wells: Submit this form within 30 days of completion of well
For muhiple wells fist all depths ifdiferent(emmple-3 2200'and 2®1001 construction to the following:
itl.Static water level below top of casing: 7 (fL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter. J� (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: i6c,I ex above,also submit one copy of this form within 30 days of completion of well
(i.e.auger.rotary,cable,direct push.etc) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLSONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: 24c.For Water Suimis&Injection 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: �•i Amount:�aD�j completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Eavironmentat Quality-Division of Water Resources Revised 2-22-2016