GW1-2023-00430_Well Construction - GW1_20230103

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WELL CONSTRUCTION RECORD fflM-IJ For httemal Use only.
L Well Contractor Information:
Cameron BaAn MWATERZONES
FROMf TO DESCRIP[IOx
Well ConttactorName OS & ft, 1 i
4518-A J a, f
NCWell Contractor CeitificadonNOber 15.OUTER CASING(for multi-cased wells)ORLRIER tfa livable
Aqua Drill,Inc. CROM To DLtMEfER 'TfficxNES3 MAI�AL
yS
Company-Name / /f 16.INNER CASING ORTUBING( ctmen-100PI
2.Well Construction Permit#: t¢Q� / FROM To DIAM t T JUUN 5S rtATrrniAi.
List allappiicable well cotutructfon permits C.&UIG COralty.Stale Yarlonm etc)
ft:
ft it in.
3.Well Use(checkwell use):
Water Supply Well: FROMI PTO DLIMETBR SLOT SIZE MUCKNEss MATERIAL
cultural Muni cipaUPublic fL & m
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt in.
Industrial/Commercial 13Pwidential Water Supply(shared) 18.GROUT
i •Irri tiOn FROM1 TO MATERIALEMrpLACE[�NTMETROD&AMOONT
Non-Water Supply Well: O 2 �
_. Monitoring FIR-covery tt
Injection Well: IL I ft
Aquifer Recharge OGroundwaterRemediation 19.SAND/GRAVEL PACK>f livable.'"
quifer Storage and Recovery E3SIdinity Banier FROMTO MATERIAL gMgpLACEMEN7 METHOD
FlAquiferTest OStornw aterDtainage fL
_ Experimental Technology t39ubsidenee Contml 11L
Geothermal(Closed Loop) EITracer 20.DRILLING LOG Cattach additional streets if
FROM TO DESCRI-MN(colorbanbmw.soWmck e.o m'nsae.eta)
Geothermal(Aeating/CoolingRetum) - Other-(ex btinunderMlRemarks) g,
&Date Well(s)Completed: Well ID#
ft. ft.
5a.Well Location:
R. ft r
Fact1'510wn Name FacilityMifffapplicable) fLfL
EL ft.
Physical Address,City,andZip
"Y a fL JAU 0 = 2023
2L REMARKS
county ParcelIdentiEcadonNo.(PIN) F,
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(ifwcll field,one IWIong is sufficient) � 22.Certification:
W _ f3
���••• S�gua[urc '
6.Is(are)theweII(s�rt'ermanent or ( Temporary
)TT ofecaffled WellContractor Dam By signing this form,I hereby certlfp that the we11(s)xns(it+ere)consinreted in accordance
7.is this a repair to an existing well: []Yes or __ No viih 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out knotm well construction in orma on and explain the nature ofthe copy ofthis record has been provided to the aril mvner.
1.
repair under 621 rawarla section or on the back of illisforat. 23.Site diagram or additional well details:
Yon may use the back of this page to:provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only IGW-lisneeded.Indicate TOTALNUbMERofwells coastructirmdetar7s.Youmayalsoattachadditionalpagesifnecessary.
drilled: SUBMTITAL INSTRUCTIONS
9.Total wen depth below land surface: (�) 24s.For All We1Ls+ Submit this form within 30 days of completion of well
Forrmrinpfeivellslistalldepthsrfdierent(example-3v200'and2@100) construction tO the followmg:
10.Static water level below top of casing. 7 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.rue`t/j 1617 Mail Service Center,Rale%b,NC 27699-1617
11.Borebole,diameter. b C-) 24b.For Injection Wells: In additi I to sending the form to The address in 24a
.r above,also submit one copy of this form within 30 days of completion of well
12.Well coustmetion method: l tom!` / construction to the following:
(ie.auger.rotary,cable,dbeetpusb,etc.)
Division of Water Resource%Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 00" 24c.For Water Supply&Iniectioa Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: h k Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nodh Camlina Depad=nt of Bnvimnmenml Quality-Division of Water Resomres Revised 2-22-2016
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