_Well Construction - GW1_20230310 (49)

•
/ • le Print Form
/ WELL CONSTRUCTION RECORD(GW-1� For Internal Use Only.
L Well Contractor information:
Cameron Bazin 14.WATER ZONES
FROM TO DESCRIPTION
Well Contactor Name NS fi: ft. 10 6ig'
4518-A ft. rt.
NC Well Contractor CedifrrationNumber 15.OUTER CASING(for multi-cased wells)ORLINER(ifa licable)
Aqua Drill,Inc. FROM TO o in.DIAMETER THICKNESS MATERIAL
fl yIZ 1 6I
� Pu
CompanyName 7 16.L�1NER CASING OR TUBING(geothermalclosedaoop)
2.Well ConStrnetionPeromt#: 0© �G7 p �/ FROM TO DIAMETER 'THICKNESS MATERIAL
List all applicable well construction penults(i.e U1C,County;State Variance,etc.) ft. ft. In.
ft. ft. in.
3.Well Use(cheek well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE 'THICKNESS MATERIAL
gricultural DM►micipal/Public ft. ft: in.
Geothermal(Heating/Cooling Supply),Residential Water Supply(single) fl: ft. in. •
Industrial/Commercial OResideatial Water Supply(shared) 18.GROUT
i Irrigation FROM TO -. MATERIAL EMPLACEMENT ME HOD&AMOUNT
Non-Water Supply Well: 0 ft 23 ft .,i tr7 S
Monitoring Recovery ft. ft. •
Injection Well: ft. ft.
Aquifer Recharge f GroundwaterReinediation 19.SAND/GRAVEL PACK(if appli cable) •
Aquifer Storage and Recovery DSalinityBanier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwaterDrainage \ f-. ft
ExpetitnentalTechnology DSubsidenceControl ft. ft.
Geothermal(Closed Loop) ©ITlacer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrocktype,grain sten e1e)
Geothermal(HeatinglCooling Return) ``,,lam/Other(explain under#21 Remarks) ((p ft. 44�,V
4.Date Well(s)Completed:
'11/41 Well MN It° if- 2 5 ft. glade-
ft. ft. ;'
5a Well Location: "-,r--., V
a9 ,
O l�vcr 11l9;11.6 ivl `)
Facility/Owner Name Facility.m#(if applicable) ft ft �ft 1023
/ R fr.
�s6e toil' Ave. W I!7-+c:ko. ' N ',,;;-
Physical Address,City,and.Zip ft. ft. ;r1 }'`'..:''`0 U r n e
ca
/ Gi 1d a ai ba\. 21.REMARKS
County Parcel ldentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,ono lat/long is sufficient) 22.Certification:
Signature of Certified
6.Is(are)thewell(s�ermanent or (.Temporary
tractor Date
By signing this form.I hereby cerg.that the well(s)was(were)constructed be accordance
7.IS this a repair to an existing well: i[�Yes or
No with 15A.NCAC 02C.0100 or ISA NCAC 02C MOO Well Construction Standards and that a
Phis is a repalr,fits out known well construction informatt n and explainthe nature of the copy of this record has been provided to the omit roomer
repair under#21 remarks section or on the back of thisfarnt. 23.Site diagram or additional well details:
You tnay 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
conshuction,only lGW-lisneeded.Indicate TOTALNUMBERofwells
construction details.You nay also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 22-5 (ft) 24a.For AR Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdifferent(example-3®200'and 2QI003 construction to the following:
10.Static water level below top of casing: Si OWDivision of Water Resources,Information Processing Unit,
If water level is above casing.use"_" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ‘ (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.
(La Well construction cable method: p� � construction to the following:
(ix.auger,rotary,cable,directpusb,etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 e Method of test: 5/4% 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:' tit If Amountao Z.— completion of well construction to the:county health department of the county
where constructed. i I
Form GW-I North Camlica Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016