GW1-2023-02422_Well Construction - GW1_20230404

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WELL CONSTRUCTION RECORD(GW 1) For Internal Use Only: -- --
1.Well Contractor Information:
Cameron Bazin
14.WATER ZONES
Well CoatractorNanc FROM TO DESCRIPTION
4518-A j DS f- —
3r je�
ft. ft.
NCWefl Contractor CertifrcationNumber
15.OUTER CASING(for multi-cased wells)ORLINER(if applicable)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft 9 t ft: in- Pk'
00 ��Q 16.INNER CASING OR TUBING(geothermal dosed-loop) •
• 2.Well Construction Permit#: c FROM • TO DIAMETER THICKNESS MATERIAL —
List all applicable twit construction permits(Le.UIC,Comn4;Slott Variance,eta) ft ft. in.
3.Well Use(cheek well use): ft ft is
Water Supply Well: 17.SCREEN
gricnitmral Mu FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
nicipalpublic . ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial Residential Water Supply(shared)
Irrigation
18.GROU1
" FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft, 2._ ft ,
c�iii;e'
Monitoring Recovery ft. ft
Injection Well:
quifer Recharge f. It'
GmundwaterRemediation
Aquifer Storage and Recovery Salmi Bather 19.SAND/GRAVEL PACK(if applicable) •
FROM . TO MATERIAL EMPLACEMENT METHOD '
Aquifer Test QStonnwater Drainage ft ft.
Experimental Technology DSubsidenceControl ft. It.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) flOther(explain under#21 Remarks) -mo TO DESCRIPTION(color.hardness mWrec type ggrain size etel
w
t ?0
4.DateWells)Completed: 3/(7/L3 VtrelllDli: � ft- [} pt � �e-., '
ft. It. _
. 5a.Well Location:
7'hti fnat [/)r i. it '-
y`'),
Facility/OwnerNatre FacnitylD#(if applicable) ft. ft.
`3`17 ; of-Aso-) a /Iftt Al'r1r 1L . APRc/ �f 7073 •
Physical Addrcss,City,and Ztp ft. ft.
,G((l% 21.REMARKS. urn. ,,,./•..,.• i 1. .•r.:y'-714 i.)ir':Y
County +Y t-%`4'V tu'./1,,i
Patr'el Ideation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
. (ifwell field,one'along is sufficient) 22.Certification:
3 6, Viol N RC?,�-, 37� w _��—
6.Is(are)the well(s) ermanent or EITemporary Sigaaturc of Certified Well Contractor Dale
/ZIT
this form,I
constructed in accordance
7.Is this a repair to an existing well: IDYes or o with 1signing
A NAC 02C 0100or SA NCAC 02C.020cera•that the (0)Well Cons war truction tion Standards and that a
If this is a repair,fill out knows,wel!construction informal'a and explain the nature of the copy ofthis record has been Provided to the xrl!owner.
• repair under#21 remarkasection or on the back oftlds rut
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 I GW-I is needed_ Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessiuy.
drilled:
2 S SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ( ) 24a.For All Wells: Submit this foam within 30 daysof completion letion of well "
ifdt
For multiple wells list all depths jferent(ermnple-3@200'and 2@100) p
r, construction to the following:
10.Static water level below top of casing: 9 d
Ifwate-level is above casing,use+• (ft.) Division of Water Resources,Information Processing Unit,
ry 1617 Mail Service Center,Raleigh,NC 27699-1617
I L Borehole diameter. (in.)
24b.For Infection Wells: In addition t&sending the form to the address in 24a
12.Well construction method: (61.
44-p above,also submit one copy of this form within 30 days of completion of well
(ia auger,rotary,cable,direct push,etc) construction to the following:
FOR WATER SUPPLY WEI:I C ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 762 Method of test: Sr y„,,1 24c.For Water Supply&Infection Wells: In addition to sending the form to I
type: / the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection !!// Amount: ko completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Dep
artment of Environmental Quality-Division of Water Resources Revised 2 22 201E