_Well Construction - GW1_20230315 (59)

Print Form 7
WELL CONS�'RIICTION RECGRD(GVE�11 For 7ntemal Use Only.
L Well Contractor Information:
G'
Cameron Bazin 14_WATERZONES
VMl CommoorName FROM TO DESCRIPTION
4518:A `t� �D
�
NCWeli Contractor Cerdlica6onNmnber R. ft.
15.OUTER CASING formolti-wsedwells ORLI[VER efn ffcable.
Aqua Drill, Inc. FROM TO DL4NHTER THICKNESS MATERIAL
O fL 7/ ft.. ` in. G
CompalryNnme r
�� V ) '3 16.INNER CASING ORTUBING(geothermal doseddoo
2.Well Construction Peradt#: f✓ FROM TO DLAWIMR THICIQYESS MATERIAL
Lest all applicable Kill croustruc6onpamas tie UIC,Cormtp Stale Yariant�etc) R ft. [u.
3.Well Use(ebeckwell use): ft. fL is
Water Supply Well: 17.SCREEN
AP,,ticulturdl FROnr TO DIAMMIZ SiAT512E TnICKNESS MATERIAL
Municipal/Public ft It
Geothermal(FleatinglCooling Supply) Residential Water Supply(single)
it ft
IndustriaUCommetaial E]Residential Water Supply(shared)
18.GROUT
i Irrigation FROM TO MATERIAL EMPLACEMENTbWMi➢&AMOUNT
t'Aquifer
Water Supply Well: O g, 2 G i'
nitoring Recovery g ft
tion Well:
uifer Recharge tt n
d (3roundwaterRemediation
uifer Storage and Recovery S gym 19.SAND/GRAVEL PACK ifs ticuble
ty ORI TO afATERfA1•: EMPLACMMMUMETHOD
Test OStormwaterDrainage fL IL
Experimental Technology DSnbsidence Control ft. fit
Geothermal(Closed Loop) DTraoer 20.DRILLING LOG fattneh additional sheets if nesess
Geothermal(HeatinglCooling Return) 0Other(explainunder#21 Remarks) FROn1 TO DESCRMTMN miar.haednest,soarrock rain size.ern
fL fL ltwa
4.Date Wells)Completed: Z Well M# �k it 5 y fit
5a.Well Location. nn ft ft.
Facility/OwncrName FaailityIDll(ifapplicable) ft. ft. v. ;� -zv. .•�
IL
Physical Address,City,and Zip �' fL fit
yAct k, 2LPE5fARrrc
County ii'o d i L'
ParcelIdentifica6oallo.(PII�
56.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(ifwclt field,one ladlongis sufficient) 22.Certification:
344. Z' iY
6.Is(are)the we11(s)0—anent or IMTemporary Sigaaluceo CemtiedWellCootmctor Date 2
� BY signing this farm,I hereby certify chat the IMU(s)Kiss(were)constructed inaccordance
T.IS this a repair to an existing well: 1�_.1'yes or i% with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 NeU Construction Standards and that a
Iffhis is a rgmlr,JtUouthnowrt well construction injormaliddn and explain the nature ofthe spy offbis record has keen provided to the umil omaer.
repair under 921 reaarla section aron the back ojthisform.
23.Site diagram or additional well details:
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
construction,only 1 GW 1 is needed_Indicate TOTALNUMBER of-wells construction details.You may also attach additional pages ifnecessaty.
drilled:
SUBMITTAL WSTRUCTIONS
P.Total well depth below land surface: 4S (�) 24a.For All Welts: Submit this form within 30 days of completion of well
Forrmdtiple sveRs list all depths ifdifferent(erampJe�3Q200'and2(a)7001
construction to the following:
10.Static water level below top of casing, Y t-�
lftwter level is above casing,use t Ems) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. (in) 24b.For ilnMon Wells: In addition to sending the form to the address in 24a
P.Well construction method- �(� � above,also submit one copy of this form within 30 days of completion of well
(Le-auger.rotary,cablq dirnctpush.etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Divfsfon of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield r
(gPm) Method of test: st al. 24a For Water Suonly&Iniedioa Wells: In addition to sending the form to E
i3b.Disinfection type:— a the address(es)above, also submit one copy of this form within 30 days of
Amount: Z— completion of weu construction to the county health department of the county
where constructed.
Forum GW-1 North Carolina Department of Environmental Quality-Division of WaturResoumes
� Revised 2 22^2016
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