GW1-2023-02425_Well Construction - GW1_20230404

- Print Form 1.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Cameron Bazin 14.WATER ZONES
Well ContmctorNamc FROM TO DESCRIPTION I
4518-A �ZS _ ft. ° (:
ft. f
NC Well Contractor CedificationNumber 15.OUTER CASING(for mufti-cased wells)ORLINERofap lleable)
Aqua Drill,Inc. FROM T1O. DIAMETER THICKNESS I MATERIAL - .
0 ft. 7,Q ft ` in. y i,t_
Company Name u
/� 1i
CO
16.INNER CASING ORTUBING(geothermal closed-loop)
. 2.Well Construction Permit# 0©i V 2" FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constrUatlItpermits(i.e.UIC Cowitp.State.Variance.etc) ft ft In.
3.Well Use(checkwell use): ft. ft. in.
Water. Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural }Municipal/Public ft. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) g. ft. in.
Industrial/Commercial. - E3Residential Water Supply(shy) 1S GROUT -
i Irrigation FROM TO ' - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff' 2 2 R C(,i.n,i
Monitoring IDRecovery ft. It YY
Injection Well:
IL it
Aquifer Recharge DGroundwaterRemediation 19.SAND/GRAVEL PACE((ifapplicable)
•
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0StormwaterDrainage ft_ R
Experimental Technology [jSubsidenceControl ft. ft-
Geothermal(Closed Loop) ['Tracer 20.DRILLING LOG(attach additional sheets If necessary)
-FROM TO DESCRIPTION War,botdness.soli/rock type,crate size.etel
Geothermal(Fleating/Cooling Return) (Other(explain under#21 Remarks). . 6, R. ., it.
4.Date Well(s)Completed: [/g0/z s Well ID# 1:7 ft- 26 5 ft: t dL
ti �a
5a.Well Location: ft. ft. 4.,—. .„.,.2 1 ` _(i` . ,
7t(t Jo%nScr-. On `e C0L3
Facility/OwnerNume FacilitylD1!(if applicable) , C
ft. ft'
«
(33 Prlf✓tr(�OCA 61 9i) r /tff ft. It ;;�„ ,1 ^1 :1t;'t
Physical Address,City,and Zip ft. ft. °" ' �
CLA Cy 21.REMARKS
County Y Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iat/Jong is sufficient) 22.Certification:
` 6.%Sj3 iv .t"QQ),. %/g-1 /w ( 22
6.Is(are)the well(s)` Permanent or E3Temporary Si (Certified Well Contractor D to
By signing this form.I hereby cert(.that the xn/l(s)nns(were)constructed in accordance
7.Is this a repair to an existing well: I[�Yes or No with ISA NCAC 02C-0700 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is arepair,fill out/mown well construction informatio,,,,,,((((((an����--derp/ainthenatureofthe spyofthisrecordhasbeenprovidedtothewallowner
repair under112l remarks section or on the back ofthisfornt 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-I is needed. Indicate TOTAL NUMBER of wells consh-action details Youniay also attach additional pages ifnecessary.
' drilled:
SUBMITTAL INSTRUCTIONS
depth below land surface: 2�5
9.Total well
( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a@20D'and 2(gI00') construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use+•• 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
l` above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1�/ f� construction to the following
tie.auger,rotary,rail;dtectpush,etc.) YYYP
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: f 1636 Ma Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of test: /�rl r 24c.For Water Supply Se Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one1 copy of this form within 30 days of -
13b.Disinfection type: (TIL Amount: construction, completion of well to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22 2016