GW1--03712_Well Construction - GW1_20230602

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WELL CONSTRUCTION RECORD(GW-fl) For Internal Use Only:
1.Well Contractor Information: I
Cameron Bazin 14.WATER ZONES
wallCouraetorName
FROM TO DESCRIPTION
457 8 A 38 S s. ft. S(P'''
ft. ft.
NC Well Contractor CettifirationNomher 1S.OUTER CASING(for multi-cased wells)OR LINER(Ran licable)
Aqua Drill,inc. FROM TO DIAMETER THICKNESS 1 MATERIAL •
0 ft. 6© ft / in. Yv1v�
Company Name K7
�^' �J 16.INNER CASING OR TUBING(geothermal closeddoop)
2.Well Construction Permit#: !1 15 3 l<' FROM TO DIAMETER THICKNESS , MATERIAL
List all applicable well construction permits(i.e.UIC Count;Stab Variance,etc) ft ft in.
3.Well Use(cheekwell use): ft. ft in.
Water Supply Well: - 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft ft. In.
Geothermal(Heating/Cooling Supply) 'r+•;idential Water Supply(single) ft ft. in.
Industrial/Commercial at Residential Water Supply(shared) 18.GROUT -
t -Irrigation FROM TO • MATERIAL EMPLACEMENT METHOD&AMOIJ T
Non-Water Supply Well: 4 R'• 7 3 it Gin,:p
Monitoring EjRecovery ft. ft
Injection Well:
ft.
quifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PACK(dapplicable)
Aquifer Storage and Recovery QSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
quifer Test DStomlwater Drainage ft. R.
Experimental Technology Subsidence Control ft ft-
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach addiitianal sheets if necessary)
FROM. TO DESCRIPTION(tutor.bezdness,saltiraektype,gtaln abs.etc.)
Geothermal(lleating/CoolingReturn) 0 Other(expiain under#21 Remarks)
/ 0 ft- SO ft 7rvn2
4.Date Well(s)C®Hlpleted:'6! (7/2' Well ID# 50 I`-0.99 ' A oeyk (" F.::: ;-- :.--,
Se.Well Location: ft. It a y.
t/i err ft. St JUtiy Co7n2'
Facility/OwnerName Facility Me(if applicable) R ft
Z-to l.✓el li i.. N/+a Fe6FL ft. It. Cj: •,,,.;-`L'l9{.r,:t
Physical Address,City,andZip It R
•
• Yalklh 21.REMARKS
County ParcclIdentificationNn.(PIN)
56.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
'3 . t 8(V N &a- 511-37 w
6.Is(are)the wells) ennanent or liTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certrfy that the wells)nos(were)constructed in accordance
7.Is this a repair to an existing well: IDYea or No with 154 NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jilt out known well construction informal, and explain the nature of the Copy of this record has been provided to the welt owner.
repair wider 021 remarks section or on the back of thirform 23.Site diagram or additional well eletacls:
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 TOTALNUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface: a S
(1) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ft-different(example-3@200'and 2Qa 100') construction to the following: _
10.Static water level below top of casin g•• 't)
(ft.) Division off Water Resources,Information Processing Unit,
Ifwater level is above casing,rice"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
H.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 01 oi-„(�J construction to the following
(i.e.auger,mtary,cable,ditectposb,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)_ Method of test: /rtgti r 24c.For Water Supply&Injection Wells: In addition to sending the form to
{�/ /� the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: G'(�h►' Amount: /6r?/ 0 completion of well construction to the county health department of the county
where constructed.
Form GW I NarthCarol-inaDepadmentoflnvimnmentalQuality-DivisionofWaterResouces • Revised2222016