GW1-2023-01254_Well Construction - GW1_20230127

Print Form_
WELT.,CONSTRUCTION RECORD(GW-11 For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin 14-WATMZONES
Wcll Contractor Name FROM TO I DESCRMION
5' -
4518-A
rt. fL
NCWellContnetorCefhricationNumber 15.OUTERCLISING formniticasedwelis ORLINLR da cable
Aqua Drl11,Inc. FROM TO DIARIETL+I2 THICEQYESS MATERIAL
ft, o & in.
CompanyNatne
^��/'C 16.INNERCASINGORTUBING thermaldwed-]oo
2.Well Construction Permit#: U (�7 FROM To Dixnat:•rcii TmCKNESS I MATERIAL
List all applicable wall caustraction permits r e.UIC,Countft State,Vadance,etc) M fL Im
3-Well Use(checkwell use): % fit in.
Water Supply Well: 17.SCREEN
FROM TO DiAMEIER SLOTSIZE TAICKNTM MATE IAL
gricultuml OMtmicipallPublic fL & io.
—Geothermal(Healing/Cooling Supply) JgResidential Water Supply(single) ft. ff. 111.
lndustrial/Commercial Residential Water Supply(�baied)
18.GROUT
i Inii ation FROM TO •- MATERIAL EMPLACEMENTMETHOD&AMOUNT
Plow-Water Supply Well: R fL IL r
Monitoring , Recovery fL &
Injection Weil: ft IL
quiferRecharge OGroundwaterRemediation
Aquifer Storage and Recovery OSalinityBarrier FROnSAND TO lGRAVELPAC 1 MATERIAL
ifamilicab c EMPLACEMENTRi1TItoD
Aquifer Test OSto>mwaterDtainage
Experimental Technology OSubstdenceCoollrul
- Geothermal(Closed Loop) DTM= 20.DRII.LING.LOG attach additional sheets if necessary)
Geothermal(Beating/Cooling Return) —Other(explalnunder#21Remarks) FROM fL To I DESCRIPTION curmthardntmsoatrack sizr,cue.
ft ,
4.Date We1l(s)Completed:_&_/K/%4,Well IDf M R' -
Sa.Well Location: R ft.
Facility/OwnriName FxdityID9 fapplicable) ft. iL ^'-
1941Akia far^ ilk 512 n fL ft 7 207-1
Physical Address,Ci1y,and Tap ft. &
21.RENIARKC
!�A 62V
County ParcelIdentifieationNo.(PiN)
5b.Latitude and longitude in degreesWinites/seconds or decimal degrees:
(ifwcll field,one Wong is sufficient) 22.Certification:
Tog- W 2
6.Is(are)thewell(s) . ermanent or.OTemporary Signature oKertified Well Contractor Date
By signing dris form,I hereby certify that the iwX(s)um(here)constructed in accordance
7.Is this a repair to an existing well: IYes or 10 with RSA NCAC 02C.0I00 or 15ANCAC 01C.0200 Well Construction Standards and that a
Ifthis is a repair,fill our town well construction informatlo and equals the nature of the copy afthis record has been provided to the aril owner
repairunder011 remarFsswdon eron diebackofdtrsfon
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells baving the same You may use the back of this page to provide additional well site details or well
construction,only l GW-1 is needed Indicate TOTAL14UMBPA of wells construction details.You may aiso avaciradditional pages ifnermsary.
SIISMITIALINSTRUCTIOIVS
9_Total well depth below lead surface: / Z 00 249.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list alf depths ffdifferent(example-3 a@200'and 2@100)
construction to the following:
10.Static water level below top of casing: 1/D (it) Division of Water Resources,Information Processing Unit,
rivater level is above casing:rise't" 1617 Marl Service Ginter,Raleigh,NC 276994617
IL Borehole diameter. (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit e copy of this form within 30 days of completion of well
12. g construction method: �ofi�tti awconst construction to the following:
(i.e.auge,rotary,cable,dinxtpush,etc.)
DivisionUnderground
FOR WATER SUPPLY WELLS ONLY: 6 Mail Service CenterRaleigh,NQ Program,
C 2 699-1636
13s.Weld(gpm) 3 Method of test: r 24c.For Water Supply&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: Amount:. completion of well contraction toj the county health department of the county
where constructed_
Form GW-i North Carolina Department ofEnvaonmenhd Quality-Division of WaterResoraces Revised 2-22-2016
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