GW1-2023-02219_Well Construction - GW1_20230307

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATER ZONFS
FROM TO nFscRlrrtc�N
Well Contractor Name ft. ft• `�L �(;T
4518-A ft. ft•
NCWellCantmclorCettificalionNumer is.OUTER OR)IlsER da ]icablc
b
Aqua Drill, Inc. FROM1t TO D IAL
IA �R TiiICkNESS MATER
ft. h ft. ( in.
CompanyName J ` 16.INNER CASING OR TUBING( eo:chermal dosed-fors
FROM TO DUFSETEF:_ THICh"PiESS MATTRIAL
2.Well Construction Permit#: 1 Yf R, ft. Ins
List all applicable cell construction permits 6-UIC,Cotatty.Stale.Variance,etc.) _
fL fL in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THictcnFss MATERIAL
Agricultural 0MunicipaV?ublic fL tt. la
Geothermal(Heati.gtCooling Supply) Residential Water Supply(single) ft. ft• in.
Indust.aUCommercial 0Residential Water Supply(shared) 13.GROUT FROM TO MATERfAr__ EDTPLACEMENr M1IETHOD&AM1IOUN'T
Frri atiun
Non-Water Supply Well: ft
Recovery I L
Monitoring � —
In'ection Well: ft. ft.
Aquifer Recharge DGroondwater Remediation 19.SAND/GRAVEL PACK if a liu:blc
Aquifer Storage and Recovery salinity Bawer FROM TO MATERIAL T::
7—,
METHOD
Stormwater Drainage ft. M
Aquifer Test �� g —
Experimental Technology Subsidence Control ft ft _Geothermal(Closed Loop) DTraca 20.DRILLING LOG attach additional..^.hash if neTO DESCRn'TTON color,hin sizq r[el
Geothermal(Heating/Coolioe Return) __ Other(explain under#21 Remarks) g
c
4•DateWell(s)Completed- w We11ID# ft. l'�inJ ft• 1i ?�i
ft. rt.
5a.Well Location:
ft, tL
Facility/Owner Name Facility ID$(if applicable) —
�.i [L
ft.tt -
o ' ° ft.
Physical Address,City,and Zip
,• i 21.RENLARKS —_ -
_ --
County Parcel Identification No.(PIN)
i
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees: --
(if well field,one laglong is sufficient) 22.Certification:
Signature ertified Well ontrector 6.Is(are)the wetl(s)OPermanent or Temporary Dam
g},signing this form,I hereby ceffifj'dtrnt the svell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: I]Yes or allo with 15A NCAC 02C.0100 or I5A NCAC 02C_0200 Well Comiraction Standards and that a
copy of this record has been provided to the well otmer.
Jjfleis is a repair fill out Ialotvn wail construction injormati�(and explain the nature oJthe
repair under k21 remarks section or on the back of th&form_ 23.Site diagram or additional welt detai3s:
8.For GeoprobelDPT or Closed-Loop Geothermal WeM having the same You may use the back of this page to t c provideess
additional well site details or well
construction details. You may al:o attach additional pages ifnecaty.
construction,only i GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple ivells list all depths ifdienme(example-3@200'and 2@1001 construction to the following:
to.Static water level below top of casing: 1 (ft.) Division of Water Resources,Information Processing Unit,
Jf rater level is above casing,use-4 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy o:P this form within 30 days of completion of well
12.Well construction method: ��(7 lil(J construction to the following:
(i.e.auger,rotary,cable,direct push,ctc.)
Division of Water Tiesoura.s,Underground Injection Control Program,
FORWATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm} Method of test: 5, 24c.For Water Supply&Iniectiou Wells: In addition to sending the form to
the address(es) above, also submit one copy of this forma within 30 days of
completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed_
Form GW-1 North Carolina Department of Environmenatl Quality-Division of Water Resources Revised 2-22-2016