GW1-2022-00150_Well Construction - GW1_20221219

Print Form_
WELL CONSTRUCTION RECORD(GW-1) Forh t malurw only.
1.Well Contractor information:
Cameron Bazin 14.WA77ntzON&4
Wdl Comnctm Nam, 1111001 1 TO I uescwrTIM
4518-A 585 R R z
R. R.
NC Well Cantutor Cettifiwtion Number
i5.0IIfIDt G mvltiawd wens OR LINER d Rrab
Aqua Drill, Inc. hxad To nuu,E xx 1HICRNrSS MA7anAL
OR 8sp R 6 in.
CompntryNan><
/,q 14II4NERCASINGORTOBING("a tbermaldmed-Ioe
2.Well Construction Permit#: O30y1 FROM TOntA^tcrR.n 'r®errnres M&TERML
List all apP7iwLle aetl roruhvction PeaNs#.e UIC Comte.Stma Yariaae aM) R R In.
3.Well Use(check well use): 8' R in.
Water Supply Well: 17.SCREEN
FROM I I M!"IrrPA I81ArraIIH 'IRICartB45 MAtiRIAL
Agicultuml E)MunicipalfPubnc it, a. in.
GeoWemml(Ifeating/Cooling Supply) Residential Water Supply(siagaij R R le- _
Industrial/CommercialResidential Water Supply(shand)
1&CRODT
Inigstion, Fa06i i0 MAi6arAr. BaRfACffi1felIMENOD&AatOWR
Non-Water Supply Wen: Q R- R- G
Monitoring QRecovery it R
Injection Well:
uifer Rechmge DGmundwaterRemediation It. it
Aquifer Stmegie and Recovery Salinity Barrier .SMIDMRAYFLPA(7i
Aquifer Test [3Stormwater Drainage B- I IL
F.rperimeatal Technology OSubsidencii Control IL I JL
Geothermal(Closed loop) ®Tracer 20.1MD.iIl4GLOG wd"ddown,if
Geothermal(Reating/Cooling Reams) rJORter(ea hmuudu#21 Remarks) aBoaf m affirm rmr s.m vea ae.
R R
&Date Wells)Completed: l j Well ID# R R R,9EL
Sa.Well Location: it. R
C r p • AaN e S R R
Famtity/t)esn(r Name Faeiliry iDa(ifapplieabE) R tL
�Cvl�iarLrl !f/li/ DO�yS�,� IL R
Physical Address,City,and Tap R R DF ,. I
n.REMARKS
County -� — Parcel ldeotifieationNa.IPIM
5b.Latitude and longitude in degrees/minutedseconds or decimal degrees:
(;fweR S,IQ rum In0ovg is sails ieat) ZL Certification:
3L. 3Af33s yy N iQo 68318 Vv xs�^
6.I3(are)the wells erruan®[ or Temporary Sisa¢uc Orcatwmd Wdi Comactw D1
Bp signing fhtsfona f berrhy wo,Aw the ndl(s)uw(aere)cmunuard in a orir.,
7.Is this a repair to an e>istingwell: ©Yes or No withlSANCACO2C.OIOOor15ANCACO2C.0200We11Consaacti StmtdardrmWthata
ffntis irarepalr fill our brown�wJl mnshuction irformaa nvnd explain tl¢nature ofthe ropyofth&ret rd has beanpr M&d to rhewdlowner.
n7uir under#21 rMarAx sedan or on 0¢back ofdusform.
23.Site diagram or additional will deters:
S.For GeoprobelDPT er 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 I GW-1 is needed Indicate TOTAL NUM13ERofwells construction details. You may also attacit additional pages ifnecessary.
dined' /' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (7 ZS (fL) 249,For Ali WeEr. Submit this form within 30 days of completion of well
Forrnrfriple svef4liwa17 depths if6fferent(exnntpk-3@200'aM2(r4100)
(� construction to the following.
10.Static waterlevel below top of casing: /d (fL) Division of Water Resources,Information Processing Unit,
7janta icier a above rnsing,use•'-" 1617 MaR Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:— - (ism) 24b.For Injecton We0s: In addition to sending the form m the address is 24a
12.Well constmetion method: /O above,also submit one copy of this form within 30 days of completion of well
iit anaey mmry,mblF dLe,t Pasb,ar.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1 Z Method of test:_ &A-C_ g' _. 24c.For Water Suodv&foiection 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 _ Amount �(L fi completion of well constmctim to the county health depatmrent of the county
where cotmauc[ed
Form GW-! Norm Camhrm Depamcent of Envuonmcaml Quality-Division of Water Resotecas Reviud 2-22-2016