GW1-2022-06620_Well Construction - GW1_20220711

C3 lrrctor Ld'ormation:
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le►Oln Bazin
�t CorName 14.WATERZONES
4$ &� FRonf To DEscnrpTrON ?'
ft, IL
NC Well Contractor CectificatiouNumber tL �
Qua Drill, Inc. 15-OQTERCASIIdG formN4rasedSvefLs OBLIIdER(ti licabte
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=PROM TO��S'Name Du+nfereR THiCtOgESS AtATER1AL
,��^^ �( ft. 0 It in.
2'Well Construction Permit#: �/�J 8 3 10.MNER CASING OR TUBING eothermnl closed-loo
Lfst all p r FROM1i. TO DIAmErEtt TfiICKNESS MATERIAL°PPllcablexnAcottstruclion ermnits Le.UI Catrn State,Variance,etc) ft. '
ft. in.
3-Well Vise(check Wetf
ft. fL [n
Water Supply well:
_A�caltulgl 17.SCREEN
FROM1i TO .DIAMETER SLOTsr7di THiCKNMS MATERIAL
icipallPublic fL iL in ;
�� 1(FleattnglCooling Supply) Residential Water S 1
uPP y(single) ft in
IndnshzaUComnreruial Residential Water Supply(shared)
talion 18.GROUT
NOIF— FROM TO MATE(UAL EMPLACEMENT METHOD&AMOUNT
�PPly well: tL S tt 6WAS
Monitoring Recovery
injection Well: ft
i
Aquifer Recharge ft. fL
DGro�dwater Remediation
Aquifer Storage and R19.SAND/GRAVEL PACK if a ticable
{! Recovery �Salinity.Barrier7;t�
M1rATERfAI. EMPLACEMENT METHOD
Test OStormr�aterDrainage R
Experimental Technolo gY Subsidence Control fL
' Geotheunal(Closed Loop) [iTracer 20.DRUJJKG LOG attach additional sheets if necessary)
i Geothermal(HeatinglCooling Return) .- 01her(ex lain under#21 jwk.)'
FRonf To DESCRIPrIUN colrhnrdncvmvrack .tze erad[[ fL O ft.
4-Date well(s)Completed: [7 Z yWell ID# ft. jj
' Sa.Well Location:
& f.
Facility/OwnerN[axne !-WL Sr�— ( Fae�lityIl3t#(/ifapplicable) fL fL C � F F O
1 �p Ltd �t`N Sfir �Ci �Ir�lYfDt&O�i t��/ ft.
n T. ,
it It 2
! Physical Address,City,and Bp
21.REMARKS
C�� Parcel Identification No.(PIN)
t P5" b�TiC3PF' t ."�v� �I
5b.Latitude and Iongitude in degrees/minntes/seconds or decimal degrees:
(ifwcU field,one lat/long is sufficient) 22 Certification:
53 Fro. Y�ZY3 w -, G A ZrL i
Sipah re of Certified Well Contractor Date
6.Is(are)thpwell(s) anent or OTempor3ry i
'`$ysigning thrsjomt,I hereby ceryfy that the ive)!(s).vas(were)constructed in accordance 4
}with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Fs this a repair to as ezLsting we1L Yes orNo E
fr fill otd7atown we11 eans1ra 0n informalia and explain the nalure of the copy ofthis record has been provided to fire wvIl arvnvr. I
Ift)tfs is a repo fi 23.Site diagram or additional well details: E
repair under#r21 remarks section ar an the back ojllnis jams t
Geothermal Wells having the same You mayuse the track-of this page to provide additional well site details or well
8.For Genprobe/DPT or Closed Loop construction details.You may also attach additional pages if necessary. f
cnnstTt' on,only I GW=1 is needed.Indicate TOTALNUMBERofwells 5� AL STRIICTIOIVS
' drilled: r,
I below land surface: (L) 24a.For All Wells: Submit this form within 36 days of completion of well
9. TOW well depth �n dr erent(temple_3(a310 and Qloo) construction to the following !
For mrrlffple wells list all dep f ff
oe� (ft.) Division of Water Resources;information Processing Unit,
jy level bet.ow top of casing: 1617 Mail Service Center,Raleigh,14C 276994617 i
i0.. e l is aboiae ras°rA
lJ leve 1Ab.For inie�cdoii We[Is: In additioa to sending the form io the address in 24A
(�)
7L'�reifDly diameterabove,also submit me copy of this form vtritlrin 30,days of.completion of well t
-- �, r� _ construction to the following:uet
IZ.Wry cons"etiom,i 'od: ;
��row,.cable,dbeetpus6.da) Deuteron of Wafer Resoiaccs,Underground Injectiori'Contirol Program,
Or— ONLY: 1636 Mail Service Center,Raleigh,NC 27699;-1636 f
y WFI.1(S
Mpg WAS •S&PL 24eFor Water SUpp1V&Infection Rlclls: In additionJo: j
t submit one c
the addresses) above, also suopy of th sending the form to
is form within 30 days of Method of tes i
jjeld($PT) completion of well constwcdw to'the county fien[th department of the county
jab• Amount: here
w constructed-
WOOD _
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13bu _ „ Revised2-22 z016
rlatth Cazolina Dep bwut of uvironmental Quality;Division of Water Rico