_Well Construction - GW1_20230315 (64)

Print Form '
'941ELL COIytSTRUCTIONRECORD(CM-4) For lnternal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
FROM TO DESCRtP'rtOlY
WellContractorNamc t g 5 IL (--
4518-A n• e-
NCWellConhactorCmtifccationNumber MATERLII
15.OUTERCASING formnld-easedwells ORLIl�R a liable
FROM TO DfAMETSR MUCKNM
Aqua Drill,Inc. O f1. s ft. / in. 11 v`-
CompanyName �r�yy ¢ 16.FROM INNER CASING ORTUBING eothermaldosed-loo
`J I C,y { TO DiANLErER TffiCHIVESS
2.Well Construction Permit#:_ It ft m
List all applicable well construction pennits•0 e.Ufa Count:Stag Variance,etc) i
it. R to
3.Well Use(checkwell use): 17.SCREEN i
Water Supply well. FROM To DIAMETER scorstze 'txt L
Agricultural o mmicipatimlic fL ft. in.
-Geothermal(Heating/Cooling Supply) csidential Water Supply(single) it ft. in.
IndustriaUCcumn-Mial DResidenttal Water Supply(shared) 18.GROUT y Et�LACF1w7ENT MRrxoD&AMOUNT
FROM TO
t Ini 'oil
permul
ter Supply Well: R �
oring Rec°very R
n well: B. ft.
er$echarge �GroundwaterRemediation 19.SANDIGRAVEI.PACK B liable
er Storage and Recovery Salinity Batrier FROM TO atnTERIAI.
EMPLACEMENT Mt:"IROD
er TestStormwaterDminagefLmeutal Technology �©ISubsidenceControl ermal(Closed Loop) OTMcer FRDRII LINGLOG attachadditonalsheetsaFRont To(IieaBng/CooUng Retum .—Other(ex lain under#21 Remarks) l J Ft fn.
4.DateWell(s)CGMP1eted: Z Z WillID4
Sa.WellLocatiow R. ft.
Facility/OwnerName Facility ID#(ifapplicable) _., .•, -_
r 1 , n. ft.
2 V37 G,Iednwr !.l,s 'n� r'� YG k, v i � +t. MAf;
Physted Address,City,andZip
Y 2LREMARKS I'
County Parcel ldentificationNo.(PIN) -
5b.Latitude and longitude in degreeslrniuutestseconds or decimal degrees:
(tfwcll flcld,one
alaatilongis sufficient) Q 21 Certification:
SigaatutcofCeRified WellCumttaetoz� Date
6.Is(are)the we➢(sermaneat orTemporarq that the,cells wire constructed in accordance
BY signing this fount 1 hereby certijp ()was( )const
7.Is this a repair to an existing well: oves or with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 llrell Construction Standards and that a
Ifthis is a repair,fill out latotn well tottstruction injormatio and explain the nature of the copy ofthu'record has been provided to due well owner_
repairunder021 rernarkcsection oron the bprkojthisjorm 23.Site dia�m oradditional well details-.
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction r use the track this page provide additional well site details or well
construction details.Youu may also attach additionsl pages ifnecessary.
construction,only 1 GW-1 is needed.IudirateTOTALNUMBERofwells
drilled SIIBIVQTTAL INSTRIICTI0I�SS
P.Total well depth below land surface: Zn 7 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells 1W all depths Ifdifferent(example-3@2Wand 2@1001 construction to Ute following:
10.Static water level below top of casing: Y O (ft.) Division of water Resources,Information Processing Unit,
Ijivafer level is above casing,use"+" . 1617 Mai(Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. 41 (in) .24b.For Injection 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: ��' ��� construction tothefollowing:
(Le.auge,mtaty.cable,dvectgasb,etc.)
Division of Water Itesomces,Underground Injection Control Program,
L13a.
WATER SUPPLY WELLS ONLY: 1636 Mau Service Center,Raleigh,NC 27699-1636
ieid(gpm) Method of test: 24c.For Water Sunvly&Iniection Wells: In addition to sending the form to
L �zthe addresses) above, also submit one copy of this form within 30 days of
Disinfection type: l T rr Amount: 7 completion of well construction to the county health department of the county
where constructed.
f P.nvuommenud Quality-Division of WaterResmib= Revised 2,22 2016
Fom1 GW-1 iSorthCarolina DepaRment o