GW1-2023-02311_Well Construction - GW1_20230331

Print Form .
ILL CONSTRUCTION RECORD(GW 4) For Internal Use Only:
1.Weil Contractor Information:
Cameron Bazin 14.WATERZONES
Wcli Contractor Name FROM TO DESCRIPTION
4518-A i 2 5 it' f % (pd't,
ft. it
NC Well Contractor CertificationNmnber 15.OUTER CASING(for multi-cased wells)OR LINER(ifa licable) '
Aqua Drill,Inc_ FROM TO DLAMiITER THICKNESS MATERIAL
CompanyName 0ft. ft. ' in. Pv
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well ConstructieaPermit#: (��0 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(e.UIC County.State.Variance,etc) R. ft: In.
.
3.Well Use(check well use): ft. ft in
Water Supply WeU: 17.SCREEN
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft: ft. in.
Industrial/Commercial OResidential Water Supply(stated)
i8.GROUT
i Irrigation FROM TO ' - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20ft. Cl !'
Monitoring Recovery ft. ft ) -
Injection Well:
R f.
Aquifer Recharge (1Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable).
Aquifer Storage and Recovery QSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Et Stormwater Drainage ft. ft .
Experimental Technology +DSubsidenceControl ft ft
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(HeatinglCooling Return) Other(explain under#21 Remarks) -FRoat To
ft. DESCRIPTION(color,hardness salt/rock true grata eke etc.)
n ?ljc, ft E7 l jr.
4.DateWell(s)Completed: ���z•� Well ID# 8,9 -'� (!g S it P CIL.
. 5a.Well Location: ! ft. it
,�
, lee ft. ft 's , 4 I mo,
}RE-1 r�c Gi,� t�>•v,
Facility/Owner Name facility IDA(if applicable) ft. ft.
JCL;:+9l'o:1 (ee A .• A,� �t ft. it MP,R 1 1_ 7(173 •
Physical Address,City,and zap R ft.
fw(fl1 Lo-f'I 0 21.REMARKS -•i 7r;';;r� :r.;I .,.
d r.,.
County. Parcel Identification No.(PIN) -
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
Orwell field,one lat/long is sufficient) 22.Certification:
344+`.771 DI 8© c2l31 w
_.___._____. ------ y v2. •
6.Is(are)the well(S) Permanent or Temporary SignatueofCertifiedWellContractor Date
By signing this form,I hereby cerl(Jp that the walls)usis(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or o with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
!Phis is a repair,fill out/mown well construction informal; explain the nature of the copy of this record has been provided to the well owner
repair under#2l remarks section area the back ofthisf • 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 ifnecessary.
{f SUBRRTTTAL INSTRUCTIONS
9.Total well depth below land surface: f (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtfferent(example-3Q2000''and 2®100') construction to the following:
10.Static•water level below top of casing: V.
e7 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use'+ 1617 Mail Service Center,Raleigh,NC 276991617
U.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to The address in 24a
12.Well construction method: (70 1-c.r above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direcrpusb,etc.) construction
the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: L 1636 Mail Service Center,Raleigh,NC 27699-1636
(
13a.Yield(gpm) /00 Method of test: 7r���/ 24c.For Water Supply&Iniection,Wells: In addition to sending the form to
J the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type �y1�i1� Amount �r r.'=-�" completion of well construction to;the county health department of the county
where constructed.
Form GW-I North Carolina Department ofEnvironmenul Quality-Division of Water Resources Revised 2 22 2016