GW1-2023-02991_Well Construction - GW1_20230425

. _ Print Form -`
WELL CONSTRUCTINV I IEC'u t) ( Il.) For Internal Use Only:
1.Well Contractor Information: i•
Cameron Bazin 14.WATER ZONES
FROM To DESCRIPTION
Well ContractorNamo
4518-A 3 5 It ft' p%i
ft ft.
NC Well Contractor CertiScationNomber 15.OUTER CASING(fur multi-eased wells)OR LINER(i a licable).
Aqua Drill,Inc. FROM TO DL4t%IErER THICKNESS MATERIAL
C) (ft. (l0 ft. in. J I�C-
Company Name - 16.INNER CAS➢N GORTURING(geotheimaldosed-loop) 11 .
2.Well Construction Permit#: 363 061p FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.WC Coungt State.Variance etc) fi ft. In.
3.Well Use(check well use): ft. in.
Water Su Wel➢: 17.SCREEN
lrply FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
11 Agricultural oMunicipal Public ft it. in.
11 Geothermal(Heating/Cooling Supply) `*i'esiiential Water Supply(single) -K it. iR.
II IndustriaVCommercial *Residential Water Supply(shared) 1f&GROUT
i ;Irrigation FROM TO •' MATERIAL EMPLACEMENT METHOD Sc AMOUNT
Non-Water Supply Well: 0 f4 25 L:tl�`�,7
a Monitoring *Recovery It. ft.
Injection Well: ft. It;
*Aquifer Recharge DoroundwaterRemediation
19.SAND/GRAVEL PACK(if applicable)
al Aquifer Storage and Recovery QSaiinity Saner FROM ' TO MATERIAL EMPLACEMENT METHOD
III•. 'ferTest 05toffiwatetDrainage
it ft.
*ExperimentalTechnology °Subsidence Control ft. ft.
31 Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(cator,bardnea.soWrock tvp grain,Le.cm.)
014 Geothermal(Heating/Cooling Realm) °Other(explainiinder#21 Remarks) • R ft.
CC O (00 /4;1,,
4.Date Well(s)Completed: �V l/z 5 Wen roji / 9 ft. ?i 5 D- 1 nn oc4 .
Es.Well Location: ! ft`
dsft/ in G�((ro// ft.•
RECEIVED
Facility/OwaerName Facility IN/(if applicable) tt. R'
e,Av,,ce( v, h` ,•idiflaliGr/r-, k ft ft APR 212073 .
Physical Addsrss,City,and Zip s" 2/.RENiARICS itriumaa6avt Pr.e.: Unit
County t Parcel ident#ficationNo.(PIN) ,
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
Orwell Bald,one latllong is sufficient) 22.Certification:
-30 072C N U.2YZ. ( w /s/2
6.Is(are)the wells) Permanent or I�Temporary sigoauueofCectifisdwellContractor Date
t
By signing this form.I hereby cerg.that the rvell(s)was(were)constructed in accordance
7.IS this a repair to an existing well: Yes or :_. PIo with 15A MAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If is is a repair,fill out known well construction informal'n and explain the nature of the copy of this record has been provided to the well Dumas
repair under MI remarks section or an the back of this rat.
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 construction details.You may also attach additional pages if necessary.
drilled: $Ill3tt/il1TI'AI.IAlST1RYICEIOAIS
9.Total well depth below land surface: >S.J (ft.) 24a.For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example.3(WOO'and 2Qa I001 construction to the following:
10.Static water level below top of casing: r C, (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use+" � 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: .6 (in) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r0 fog,(�/ above,also submit one copy of this form within 30 days of completion of well
(i.e.anger,rotary,cable,direct push,etc) �/ construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163611ILan1 Service Center,Raleigh,NC 27699-1636 .
�
13a.Yield(gpm) l Method of test: 6//16. N 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of •
Wit.
13b.Disinfection type: 't t. Amount: (6 completion of well construction to the county health department of the county
where constructed.
Form Gw-1 North Carolina Departnnntof Environmental Quality-Division of Water Resources Revised 2-22-2016