GW1--03557_Well Construction - GW1_20230519

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WELL CONSTRUMON RECORD(GW-1) For hdemal Use Only:
1.Well Contractor Information:
Cameron$azin 14.WATER ZONES
Wcll ContrdctorName FR01111 TO DESCRIMON
4518-A
NCWetlConhactarCeRificalionNumber MODTERCASING(formulti-cesedwells ORL7NLR a licable
Aqua Drill,Inc. 1ROM To DZAn>EM T�c1tNr3s MOM
ft 4 J I i
CompanyName ft 1 6 in.
(� 16.INNER CASING ORT[TBING eathermaldosed-loo
2.Well Construction Permit#:-_- V Gs L+,3 FROM TO DLUVECrER TMCKNEss I MATERIAL
List all applicable wetf construction permits(r e.U1C,County,Stag Variance eta) & R in.
3 Well Use(cheekwell use): ft. % la
Water Supply Well: M SCREEN
FROM TO, DfAMETER SLOTSME THICKNESS MATERIAL
Agriculttttal 13Municipal/Public fL it. in.
_Geothermal(HeatingiCooling Supply) 7 Residential Water Supply(single) ft in,
IadusttiaUCommetcial �iD'Residential Water Supply(shared) 18.GROUT
lIrrigation FROM I To -1 MATERIAL EMI11ACF1t1ENTMEMOD&AMOUNT
Non-Water Supply Well: fL 2 i It. G l'1 t 04
r i
_. Monitoring CIRecovery ft. %
Injection Well:
ft. II;
quifer Recharge OGroundwaterRemediation
19.SANDIGRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Bather FROM TO MfATERIAL EMPLACEMM-r 5MMOD
Aquifer Test OStarrowaterDrainage ft %
ExpedracatalTechnology OSubsidence Control ft R
Geothermal(Closed Loop) E3Tm= 20.DRILLiNG LOG attach additional sheets if necessary)
Geothermal(HeatinglCoolingReturn) Other(explain under#21Remarks) FROM To DESCR1Pi'rON color,.burftess,snWrecktype,gmin sire.etc..
fL 41,111)
4.Date Well(s)Completed: E7 Well D)# 35 ft- cl ft
Sa.Well Location: ft. it.
FLfL
Facility!} vnerNnme Facility ID9(ifopplicable) fLMA y 1
V. / L'e/ fL ft. �1�
Physical Address,City,andZip R fL ifli0ii '^rl i� ^"ram,
2eA4 1(r^ 21.RErdARRC
County Rucel IdeatificationNo.(PRO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(ifwcll field,one lWong is sufficient)� S 22.Certification:
LJC�,f C7(� w 112 5
6.Is(are)thewe➢[s) Permanent or OT—porary SigoanucofCenifiedWc11Contractor Date
By signing this form,I hereby certify that the iv&(s)tsar(Were)constructed in accordance _
7.Is this a repair to an existing well: I lYes or -k o with 15A NCAC 02C-0100 or 15A NCAC 02C.0260 Well Construction Standards and that a
If this is a repair,fU outlaioiva well construction infmwatialrand explain the nature of the copy afthis record has been provided to the iveU miner.
repair under.#21 reaharb section or on tie back of tldrfAt. 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 TOTALNUMBER ofwells construction details. You may also attach additional pages ifnecessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surfacer 0Q 24a.For All Wells: Submit this form within 30 days of completion of well
For mi&Fplewells list aa&pdsifdiJfema(m,;a le-3r�a,00'and2Q1003 construction to the following:
10.Static water level below top of casing. fa (ft.) Division of Water Resources,Information Processing Unit,
Ifienter level is above casing use'+ 1617 Matt Service Center,Raleigh,NC 27699-1617
U.Borehole diameter. Z (tn.) 24b.For Injection Wells- In addition to sending the form to the address in 24a
�, 1�. above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 7`� 11C construction to the following:
(Le.auger.rotary,cable,diiecipush.etc.) .
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WMLLsS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ft 1 Method of test: �G���'� 24c.For Water Supply&Injection Wells: In addition to sending the form to
1 f the address(es) above, also submit one copy of fhis form within 30 days of
13b.Disinfection type: 1-t! Amount: (`-�� completion of well construction to the county health department of the county
where constructed.
FoanGW-1 North Carolina Department ofEavironmental Quality-Division of Water Resources Revised 2 22 2016