_Well Construction - GW1_20230327 (65)

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WELL CONSTRUCTION RECORD(GW-1) Forintemat Use Only. — - - -
1.Weil Contractor Information:
Cameron BaZIR 14.WATERZONES I
Well ContractorNamc FROM TO DES Di l
45518-A t3os fL ft. ,n
NCWeIlConlractorCettificationNumber 15.OUTER CASING(for multi-wed wells)ORIJNER ri linable
Aqua Drill,Inc. FROMTo DLA IMR TRICKNESS MATERIAL
camparryName
3 99 Z- 16.INNER CASING OR TUBING(eothermaldosed400
2.Well Construction Permit#: FROM TO I DIAMtEIER I Twclaim I MATERIAL
List a/i applicable well catstruclion permits(i.e UIC Conan:Stale.Yarlancp,eta) iL
3.Well Use(chedrwell use): ft. & in.
Water Supply Well: 17.SCREEN
�Cnittllal FROM TO DIAMETER SLOTSIZE TRICKNESS MATERIAL
Mtmicipal/Public fti ft fn.
Geothermal(Hmting/coGr g Supply) Residential"WaterSupply(single) ft. ft in,
IndustriaUCommercial OResidential Water Supply(shared) IS.GROUT
i1hrigation FROM I TO MATERIAL EMiPLACEMIENTM MOD&AMOiL7
Non-Water Supply Well: <0 fL .�? I fL C��t�
IvIonitring -Recovery fL G fiL
Injection Well: ft. ft.
Aquifer Recharge OGroundwaterRemediation
19.SAND/GRAVELPACK if Iicable
Aquifer Storage and Recovery OSaiinity Barrier FRONT TO MATERIAL I EM LACEIVM T M M013
i:Aquifer Test OStoffiwaterDrainage % IL
EExperimental Technology OISubsidenceControl & fL
Geothermal(Closed Loop) OTlacer 20.DRILLING LOG attach additional sheets if neee
Geothermal eating/Cooling Return) Olher(explainunder#21 Remarim) FROMI TO I DESCRWY[ONeolor.bnrdness,soilfmcktype.grainshzc.eta
p R O ft. o
q R%l
4.Date Well(s)Completed: Z�' L 7 Well ID# fd ft
5a.WeffLocation:
FacilitylOwnerName Faeffity ID4(if applicable) fL
Physical Address,City,and Zip J ft. fL
ke.S 21.ItEMA1i1(S I I -
County Parcel Ideatification.No.(PIN) , ;s_•, ; ,tt:: rt :' .._.,,n� Ur'!
5b.Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(ifwcli field,one lWlong is sufficient) 22.Certification: ~
6.Is(are)the well(i rzaament or ([Temporary Sigaa -fi tractor Date
B11 signing this form.I hereby cerigry that the nell(s)nos(is—)constructed in accordance
7.Is this a repair to an existing well: I]Yes or NO with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is repair fill out knoim well construction information d explain the nature ofthe copy ofthisrecord has been provided to the urli owner.
repair under#21.rentarft section or on the backoftl&form.
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 IGW-Iisneeded. Indicate TOTALNUMBERofwells constructiondetails. You may also attach additional pagesifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (f) 24a.For All\Welts: Submit this from within 30 days of completion of well
For multiple ivdk list all depths if different(brample-3Q200'and 2Q1o01 Construction to the following:
10.Static water level below top of rasing: 1 (ft) Division of Water Resources,Information Processing Unit,
lftvater level is above casing.use+" 1617 Mall Service Center,RaleWi,NC 27699-1617
I1.Borehole diameter: ( (in) 24b.For Infection 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
22.Well construction method- rb7
(Le--get,rotary,-ble,ditctp,sh,etc.) > construction to the following:
FOR WATER SUPPLY WELLS ONLY': Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Cente,Raleigh,NC 276994636
139.Yield(gpm) Method of test S 24c.For Water SunpIy&Iniection Wells: In addition to sending the form to
the addresses) above,also submit one copy of this form within 30 days of
13b.Disinfection type: 1 Amount: UZ^' completion of well construction to I the county health department of the county
where constructed.
Form GW-1 Worth Carolina Department ofEnvimnmental Quality-Division ofwaterResoun:es Revised 2 22-2016