GW1-2023-02935_Well Construction - GW1_20230425

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
L Well Contractor Information: , '
Cameron Bazin 14.WATER ZONES
Tell Contractor Name FROM TO DESCRIPTION
4518-A (6,) g. �0 L-i-
R. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap limbic)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS MATERIAL
CtmtpanyNatoe 0 R. [a c " f K�
- 16.INNER CASING OR TUBING(geothermal dared-loop)
2.Well Construction Fermis#: ± / V 7 8 ° FROM TO DIAMETER THICKNESS —MATERIAL ,
List all applicable null construction permits(i.e 1G Courtly.State:Variance.etc) r It in.
3.Well Use(check well use): ft ft. is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMtmicipa1/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R_ ft in.
Industrial/Commercial EiResidentiai Water Supply(shared) .
18.GROUT
i Irrigation FROM TO • - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: _ (9 ft 2) ' /iWe<
Monitoring ]Recovery ft. ft ° '
•
Injection Well: •
ft. fr.
Aquifer Recharge D Groundwater Remediation 19.SMD/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery OSalinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainageit ft
Experimental Technology •DSubsidence Control ft. It
Geothermal(Closed Loop) EiTiacer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.sotUrocktype,grain size.ete.)
Geothermal(Heating/CoolingReturn) fOther(explain under#21 Remarks) cic, ft 4;4 0
4.DateWell(s)Completed: /'/jy i Wel1ID# C O ft. iji S ft. am it
ft
5a.Well Location: ft'
(-�' iSr r1 r- ft. ft
Facility/Owner Name �' Facility ID#(if applicable) R. ft• P-**, 8
's fv
I
^ f. R: r L,Lg V LV.��r Q(7v- C,�l...,rvt. f WA 11 r/lG
Physical Address,City,6d4 / ft. APR ! 5 2991
Yo t 4L1� 21.REMARKS
County Parcel IdentificationNo.(PIN) 1S'-77t`"_t/£n Pr'°Z. sg Jilli
DWQ/300
Sb.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
Of wellfield,one lat/long is sufficient) ,� 22.Certification:
3F�r 19°2$ N 8 4LYR5 w j _-
6.Is(are)the well(s) Permanent or lfTemporary Signature ofCertified Well Contractor De T/
By signing this form,I hereby certify that the well(s)mu(were)constructed in accordance
7.Is this a repair to an existing well: I`Yes or .__ No with 15A NCAC 02C_0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction informjiff!
'n and explain the nature of the copy of this record has been provided to the well owner.repair .under#21 remarks section or on the hack of thisf nu. -
23.Site diagram or additional well details:
8.For GeoprobelDPT 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 constriction details.You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
�f
9.Total well depth below land surface: G7 ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3 a®200'and 2QI00) construction to the following:
10.Static water level below top of casing: (ID (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use ' 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C., (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.We0 construction method: �( 1( above,also submit one copy of this form within 30 days of completion of well
•
7 construction to the following:
(Le.auger,rotary,table,direct.pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) )a Method of test: 7cr 9/1 r 24c.For Water Supply&Injection Wells: In addition to sending the form to
ry��y the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t (7 Amount: l(r�7----. completion of well construction to,the county health department of the county
where constructed_
!Perm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016