GW1--03555_Well Construction - GW1_20230519

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Print Farm
WELL(CONSMUC '%ON RECORD LIZE 1D ForinternalUse Only. - -
L Well Contractor Information:
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Cameron BaZin 14.WATERZONES
Well Contracto£Namo FROM I TO DESCRIPTION
4518-A S fL IL Co lti,
ft.NC Well ContmetorCertificationNomber ft.
IS.OUTER CASING r multi-cased wells OTtLIi1IER d a licnble
Aqua Drill,Inc. FROM TO. DIAhfETER 7faaC1QNESS MATERIAL
CampaayName
� tis G 1�
I (i 16.INNER CASING OR (eotherzad dosed-loopi
2.Well Construction Perm iM y FROM TO I)MMErM I TMCK Ness MATntuAL
List all applicable%-ell caustmetiaa permits(X-f1l(ti COMO',State,Parlance,elr-) & R to-
3.Well Use(cheekwell use): ft. M I.
Water Supply Well: MSCREEN
FROM TO DIAMETER SLOTSIZE TRICKINESS MATERIAL
Agricultural Municipal/Pablic ft it in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R ft In.
htdustrial/Commmuial Residential Water Supply(shared) 1&GROUT
MIrrigation, FROM I To MATERIAL: _ EMPLACEMMU MEMOD&ADIOuh-r
Non-Water Supply Well: % 9 7 % ,
Monitoring Recovery ft. ft
Injection Well:
A uiferRech ft.9 urge �CrroundwaterRemediation
Aquifer Storage and Recovery S�'kit g 19.SANDIGRAVEL PACK rf a ticable
Y � FROM ' TO MATERIAL EMPLAMMEiNTMETROD
aAquifer Test OStoimwater Drainage
ExperimentalTechnology OSubsidence Controlft It
eothmmal(Closed Loop) 0TMcer 20.DRMLINGLOG irpecessmy
RGeothermal
eatinglCooting Retum) : Other(explain under#r21 Remarks) FROM TO DESCRIPTION color,hardnev,solltrOSY rain sirs ere
C C/ ft �0 Sl/tut
4.IDateWell(s)Completed: / WeRID# ft 23
Sa.Well Location: ft ft r; —,
5c�sovN ".
Facithy/OwnerName � Facib'tylD#(ifapplimble) rw ft MAY a �'7�
lm,4(u;,v,%�� ft IL -
Physical Address,dty,and ZT 7 ft %
• — kit, Parcel
Couoty Parcel IdearificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,ono ladlong is sufficient)
22.Certification:F,S 7fg't- W
� 2
6.ls(are)the well(s errnanent ' or fOTemporary SigaaMmoMerfifiedwellCantrador Date
By signing this form,I hereby certify that the iwft)was(were)constmaed in accordance
7.Is this a repair to an existing well: Oves or e with 1SA NCAC 02C.0100 or ISANCAC 02C.02001Pe11 Construction Standards and that a
Iftbtsisarep air fellout latorvarmacoavmodoniaformatlo andexplaihdianammofthe copy ofdds record has been provided to the uvUatmer.
repair under#21 reamrkssection or on the bark ofddsform.
23.Site diagram or additional well detaa'Is-.
tl.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.Yon may also attach additional pages ifnecessary.
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SUBARTTAL INSTRUCTIQNS
9.Total well depth below land surface: Z S ( ) 24a.For All Weller Submit this form within 30 days of completion of well
Formubeple wells list all depths ifdifferent(erw9le-3@200'and 2@1009
10.Static water level below top of rasing construction to the following:
�°' (ft) Division of Water Resources,Information Processing Unit
Ifrvatra level is above casing,tree+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4�^ 241a For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �� .� �J above,also submit one copy of this form within 30 days of completion of well
(U4 auger.rotary,cable,dimapnsk crc.) v construction to the following
FOR WATER ShJPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 AM Service Center,Raleigh,NC 276991636
13a.Yield(gpm) /O !r
method of leer.��� 24c.For Water SnDDiv Sc injection Wells: In addition to sending the fors to
the address(es) above,also submit one copy of this form within 30 days of
136,1Disinfeemion type: Amount,: �'C� completion of well construction to the county health department of the county
where constructed.
Fonn GP1.1 NarthCamrma Deparimentof EwAronmental Quality_Division of Water Resources Revised 2-22 2016