GW1--03337_Well Construction - GW1_20230512

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WEU,CONSTRUE IIN RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well CotttractorPlamo FROM TO DESCRIPTION
4518-A 3g5 E' ✓�,
ft. ft,
NCWell Contractor Cettification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if a,,livable)
Aqua Drill,Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name D ft 13g ft. ‘ in. Per_
�/ 16.INNER CASING OR TUBING(geothermal closed-Ioop) i
2.Well Construction Peraut#: JZ ! I FROM TO DIAMETER THICSOIESS MATERIAL
List allapplicabte xr/I construction permits(i.e.UIC,Comb;Stale,Variance;etc) ft, ft. In.
3.Well Use(check well use): ft• ft in. •
Water Supply Well: 17.SCREEN
FROM TO DTAMEiER SLOT SIZE THICKNESS MATERIAL
I `'-coitus! - QMunicipal/Pnblic ft ft. in.
Ill Geothermal(Heating/Cooling Supply) '+Residential Water Supply(single) ft ft. in.
ii I Industrial/Commercial it Residential Water Supply(shared)
1is.GR®UT ,
i 'llrigation FROM TO • MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: - 0 ft- a. ft- e ,„�
*Monitoring Recovery R. ft r�
Injection Well: -
*A fer Recharge �Gronndwaterltemediation `
ui4 �
19.SAND/GRAVEL PACK Of applUcabl
*'Aquifer Storage and Recovery OSailnity Barrier FROM TO MATERIAL EMPLACEMENT MEIBOD
*Aquifer Test QStonnwaterDrainage it. ft
a!Experimental Technology °Subsidence Control Ft It
N.Geothermal(Closed Loop) 'OTracer 20.DRILLING LOG(attach additional sheets if necessary)
IN Geothermal Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(cater,hardness,soiuroex type orate size eta)
�,2 ft i 3.2 ft �'u�-
4.Date Well(s)Completed: 9/2V2) Well ID# i 3„ ft. COS IL R nib
- 5a.Well Location: / ft ft.
it Tu
Facility/OwnafName Facnity IDS(if applicable) ft. ft: .9 $ ig 1.. 'i .r
609 AtnbFr y t1 of � tali 0o%SZ� ft. ft M,A,Y 1 m 9073
Physical Address,City,and Z" ft ft
. /(li Ulf PL ItEMAIIKS h p r,..?✓,cs�`'r3 I .i.
liNv?ni :�
County Parcel Identification No.(PIN) .a��°`
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
31. v21gj >,, ,��. 'M
g Iti ,� .�
6.Is(are)the wells) $Permanent or °Pemporatg SignhfWeliCtractor D
T By signing this form,I hereby certify that the well(s)rocs(were)consrmeled in accordance
7.Is this a repair to an existing well: IDYes or o with ISA NCAC 02C.61DD or ISA NCAC 01C.0200 Nell Construction Standards and that a
"this It a repair,fill out!mown well construction inform n and explain the nature ethe copy of this record her been provided to the well owner.
repair ander d11 remarks section or on the back of thisform.
23.Site diagram or additional well details:
You may use the back of this page'to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
' drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 110 5
FormaltipJervellsiistalldeptisifdi ferent(exmnple-3Q200 and (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
(/ construction to the following:
10.Static water level below top arming: Y
!flintier level is above casing,use+ (ff.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: . (in.) 24b.For Injection Wells: In addition to sending the foam to the address in 24a
12.Well construction method: (1, above,also submit one copy of this form within 30 days of completion of well
Cie.auger,rotary,cable,directpi sb,etc.) construction to the following
FOR WATER SUPPLY WELLS ONLY: 1636
of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) IC) Method of test: 7 17Air- 24c.For Water Supply&Injection Wells: In addition to sending the form to
yy ,(� the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: (+t(/ Amount /4)7 completion of well construction to the county health depattment of the county
where constructed.
Fawn GW-1 North Carolina Department of Fnvimamenm[Quality-Division of WaterResaatas Revised 2-22-2016