_Well Construction - GW1_20230310 (74)

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: "--
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONES
Wall Contractor Name
FROM TO DESCRIPTION
451 a A y0 `t. ft. S C- -I-1
ft
NC Well ContractorCettiftcationNumber
IS.OUTER CASING(for multi-cased wells)OR LINER(Tap Range)
Aqua Drill,Inc. FROM TO DIAMETER TRICKNESS MATERIAL -
p ft. 6'2_ ft. 6 in. iO VG Company Name
Cr
16.INNER CASING°RTC/BING(geothermal dosed-loop)
2.Well CODStruetioRpermit#; 2 FROM TO DIAMETER TtnCENESS MATERIAL
Lest all applicable well construction pennies(i.e.UIC Cowi4 Stag Parlance,eta) ft. - ft fn.
3.Well Use(check well use): ft, ft: in.
Water.Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
cultural cjMunicipal/Publc ft. ft. in.
_Geothermal(Heating/Cooling Supply) /Residential Water Supply(single) R: ft in.
Industrial/Commercial °Residential Water Supply(shared) 1S.GROUT - -
1 Irrigation FROM TO "- MATERIAL EMPLACEMENT METBOD&AMOUNT
Non-Water Supply Well: a ft 27 ft:
�:i,
Monitoring Recovery ft ft IP
M
•
Injection Well: _
ft ft.quiferRech OGronndwaterRemediation
Aquifer Storage and Recovery I(''���safjni •
B�i� 19.SAND/GRAVEL PACK(If applicable). -
f�! ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStotmwaterDrainage it R
Experimental Technology °Subsidence Control ft. ft
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothemsal(Heating/CoolingRettun) Other(explainunder#21Remarks) FROM TO DESCRIPTION(color,hardnes,soiUroek type,gadosizc.ete.)
4.DateWell(s)Completed: Z/zC/23 WeuID# 5. ft S/) R 4c)(/I I; „,_-_:' %`5'. sal
5a Well Location:
. • ft ft . ,.'.� .... 'l'-6`'FY .1,....z Okw d (toAAAS llrei:/tO-\ ft. ft. MAR i n 21123
Facilit-y/Owner Name / _ ( FacilityIDA(ifapplicabjle) ft. ft.
Li—I — 1/T c cc,A'n1 A �f�l 1 1/ ft 6tiit•rr, �5{. :f t'ct'..,v,;r ; Jib t.ii:'f
OcC /Lacc0 `c r.t;.;-t;.:,, •s
PhysicalAddtess,City,andZlp , 2 ft �'
Ak)cavoe.c. U.REMARKS
County Parcel Identification No.(PIN)
fib.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell field,one'larilong is sufficient)
22.Certification;
3 s- V.).s t
N ,g/'Z s 8 q
6.Is(are)the well(s) Permanent or Temporary SignatuureofCertifiedWellCo 'tomf�c r Data
By signing this form.I hereby certify that the well(s)sins(were)constructed in accordance -
t 7.Is this a repair to an existing well: I°Yes or p/l to with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repatr,Jltl out known well construction inforatatio nd erplaln the nature of the COPY ofthis record has been provided to the welt etvner.
repair under#21 remarks section or on the backofthtsform.
23.Site diagram or additional well details:.
You may use the back of this page to provide additional wcIl.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.You may also attach additional pages ifnecessary.
• drilled:
R' SUBMITTAL INSTRUCTIONS a
9.Total well depth below land surface: 1 l
Formudti multiple5 ( ) cons For All o Submit this form within 30 days of completion of well
P depthsrjdifferera(erample-3Q200 and
construction to the following:
10.Static water level below top of casing: Y C7 (ft-) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use +' 1617 Mail Service Center,Raleigh,NC 27699-1617
U.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition'to sending the form to the address in 24a
12.Well construction method: i 0-to{i f above,also submit one copy of this form within 30 days of completion of well i
('u auger,rotary,cable,direct push,etc.) . construction to the following
- !
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program, -
A p� l 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �Cl Method of test: t/(n 6ik o T 24c.For Water Supply Sc Infection Wells: In addition to sending the form to
• 14- the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: lit Amount I� completion of well construction to the county health department of the county
where constructed.
i, Form GW-1 North Carolina DepartmentofEnvironmentalQuality_DivisionofWaterResources Revised 2-22-2016