GW1-2023-02309_Well Construction - GW1_20230331

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WELL CONSTRUCTION.RECORD(GW-1) For Internal Use Only -�- ---_.
1.Well Contractor Information: ,
Cameron Bazin 14.WATER ZONES .
Well ContractorName MOM TO DESCRIPTION '
4518-A 245ft ft. 2S .G t,ft. ft
NC Well Contractor CertificationNnmber
15.OUTER CASING(for multi-cased wells)OR LINIfft.('dap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. / in.' fif6,
CompanyName u
F; i��� 16.INNER CASING OR TUBING(geothermal dosed-loop}
. 2.Well Construction Permit#: �./i MOM TO DIAMETER T ICKNESS MATERIAL _ .
Ltst all applicable t+eff constntctfon permits(i.e.UfC Count',State,Variance,etc) ft. - It In:
3.Well Use(check well use): ft ft. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
I Agricultural *:p unicipal/Public ft ft. in.
it Geathermal(Heating/Coolrng Supply) Aft Residential Water Supply(single) rt- B. in.
*Industrial/Commercial DResidential Water Supply(sh�d)
IS GROUT •
i :Irrigation ' PROM TO '- MATERIAL EMPIACEMENT METHOD&AMOUNT
Non-Water Supply Well: t' tt I`i it
• *Monitoring °Recovery ft. ft ' aa''
Injection Well:
*Aquifer Rechargeft. it
A
q °GroundwaterRemediation
iAgttifer Storage and Recovery 19.SAND/GRAVEL PACKCdapplicable/ •
Salinity Bawer FROM TO MATERIAL EMPLACEMENT MEnLOD
*Aquifer Test DStomlwaterDrainage ft. ft.
1lli Experimental Technology °Subsidence Control ft. ft.
111 Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
i1 Geothermal(Heating/Cooling Return) *Other(explain under#21 Remarks) FROM TO DESCRIMION(mtar bnrdness,sotvmckrype train size.en.)
ft /i ft /�
L'rJ %ftd
4.Date Wef(s)Completed: erg-°/2 3 Well Mir 6 r) ft.
-78 5 ft g,Jf(
t.
. 5a.Well Location: ft
ge 1 fait /-fo e,S ft. f '
Facili /OwaerName ft ft :.. n.•�''.-:�' ""_
Facility
..�j//5t' 6 Lr/ay �"t'!0%mi�,l ft MAR a 1 2023 .
Physical Address,City,and Zip It: ft
Sin((J ! ` � 21.REMARKS ir: t .` -�`,` :;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one let/long is sufficient) 22.Certification:
7o• 131 tl ivy, $.ZSz w /29/2. 3 .
6.Is(are)the well(s)OIPermanent or [Temporary Signature of Certified Well Contractor Date (
By signing this form,I hereby cerllfy that the well(s)ens(were)constructed in accordance
I 7.Is this a repair to au existing well: Dyes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out:mown well construction information andexplain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
1 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 TOTAL NUMBER of wells drilled: construction details.You may also auach additional pages ifnecessary.
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8S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /r (ft) 24a.For All Wells: Submit Ibis form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa200'and2(g100) construction to the following:
10.Static water level below top of casing. 1(7 (ft) Division of Water Resources,Information Processing Unit,
filmier level is above casing use"+ 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: U o IL r `_ above,also submit one copy of this form within 30 days of completion of well
("Le.auger,rotary,cable,diuectpusb,etc.) construction to the following:
FOR WAtlrM SUPPLY WELLS ONLY: •
Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 5 Method oiliest: 5.1)4 r 24c.For Water Sunoly&Infection Wells: In addition to sending the form to
�f � the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ' f-`
,Li • Amount: 6t9 2.- completion of well construction to the county health department of the county
where constructed. I
Form OW--I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016