GW1-2022-08945_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only.
1.Well Contractor information:
i
Cameron BazintF114. ATERZONFS TO WellComrnctorxamo u4518-A ftNCWellContraetorCerdficattonNumber UTERCASING for multi-ceseilwdls ORLINER ffn 6cableAqua Drill,Inc To DL Im, Trnclazess MATE1tiAL
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ComptmyName / 16.INNER CASING ORTIIBING( thermal closed-loop)
2.Well Construction Permit#: ft.
I FRoat To DULKNA&R iHic�vess w�rEitiAL
Ltst altapplicable wrJI construction penults(ce U1C,Cowd}:State Parlance etG)
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3.Well Use(checkwell use):
R&GR
Water SupplyWeU: DiAMB'rF.R SLOTSIM TMCXNess- MATERIAL
Agricultural DMunicipal/Mlic ft
Geothermal(Heating Conling Supply) Residential Water Supply(single) R in.
IndustrWCommerciat OlIcSid-dal Water Supply(�-4
liri lion .MATERIAL EtHPLACEl1ff.NTIFfETiiOD&AhfOrlN•r.
Non-Water Supply Weil:Monitoring RecoveryInjection Well: fL
quifer Rechtuge CnoundwaterRemediation PACK a licable
Aquifer Storage and Recovery OSalibityBarder FROM To blATERIAt IE111eLACEMENTI1tErt[OD
Aquifer Test �StommaterDrainage fL fL ° c
Experimental Technology OSubsidence Control ft. fL
Geotheapal(Closed Loop) Tiacer 20.DRILLING�hnachgal'sheets if nec
FRODi TON colorhmdn soNroek =ln size,etc.Geothermal(Iieating/CoolingRemm -•01her(explainuuder#21Remarks) ft
4.DateWell(s)Completed: _g V. ID# A-
ft. fr.
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Sa Well Location: if. ft 71a. �✓�
FaciraPowneri ante Faddity M9(ifapplicable)
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105o t3 �-� ll� l�✓��., ,P�G � fLft.
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Physical Addrecssss,City,and Zip REMARKS
51 oke- 21.
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degreedminutes/seconds or decimal degrees:
(ifwclll�l field,one leVlong is sufficient) ) ^�l� 22.Certification:
5 7 W
J
s,,� SigaaUucofCerti5al Well Cantrador
6.Is(are)the well(seturanent or IOTemporary
^ By slVffng this form,I hereby cerltXy that the well(:)aus(it-ore)constructed in accordance
7.Is this a repair to an existing well: lees or, o
with 15A NCAC 02C.0J00 or 15A NCAC 62C.0200 lYelf Coastruc&n,Staadards and that a
Jf this is a repair,fil!outkaonvn nve11 construction hforrrrati and esphun the nature ofthe copy ofthis record htas been provided to,the w0 owner.
repairmrder#21 reinarkssecdon oroo the backofilusforia. 23.Site diagram'oradditionl 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,only1GW-lisneeded. IndicateTOTALNUMBERofwelis constructiondebils.Yonrrrayalso;attach additional pages ifnecesstiry.
drilled: SUBMTi i'AL INSTRIICTION9'
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9.Total well depth below land surface: 2 ( ) 24a For Ail WeIIs: Submit this form within 30 days of completion of well
For mal*tewd1s list aR depths lfdllerew(ermrrple-3Q200'and2Q1Q01 constrrctionto the following:
10.Static water level below top of casing. yto t) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"I� 1617 AM Service Center,Raleigh,NC 27699-1617
11.Borehole diameter {in,) 24b.For lniecfion 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: / 61121� construction to the following:
C-atge,mtary,cable,dueetptsh.etc.)
Division of Water Besources;Underground Injection Control Progt-am,
FOR WATER SUPPLY
WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) Method of test: ' 24c.For Water SaDDly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: AmolinO completion of well construction!to.the county health.department of the county
where constructed.
FormGW4 North Carolina Department ofEnvironmentai Quality-Division of Water Rescurcas Revised2,22 2016