GW1--03710_Well Construction - GW1_20230602

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WELL CONSTRUC N•N RECORD(GW-1) For Internal Use Only.
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4518-A
5 a• ft; y 4e6,
ft. It •
NC Well Contractor CetfifivationNumber IS.OUTER CASDIGIfor multi-eased wells)ORL1NER(Rs ticable)
Aqua Drill,Inc. FROM TODLA n1LTTER THICKNESS MATERIAL -
H. (WS ft 6 in. b4i—
CorepanyName
p 16.INNER CASING OR TUBING(geothermal closed-loop) -
2.Well Construction Permit 78 Y C FROM - TO DIAMETER MK:KNESS MATERIAL _
List all applicable well construction penults(i.e.WC Coup(',State Variance,eta) ft. ft in.
3.Well Use(check welt nse): it. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural *MunicipallPublic ft. Sr. in.
Geothermal(Heating/Cooling Supply) Al'esidential Water Supply(single) ft. ft in.
Industrial/Commercial E3Residential Water Supply(shared) is.GROIIT -
i Irrigation FROM TO • MATERIAL EMPTACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft" Z?, ft 1t ti°
i
Monitoring Q1Recovery ft. ft.
Injection Well:
It. R
Aquifer Recharge DGronndwaterRemediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMEIST METHOD
• Aquifer Test DStmmwaterDrainage ft. ft
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(atnrcb additional sheets if nerees.ry)
Geothermal(Heating/CoolingRet Return) DOther(explainunder#21 Remarks) FROM TO DEscst>plToly(enWr,F,ardnrsr,sotvraNitvpe prafaslm ere)
j
t7 ft S f. ce,0
4.Date Well(s)Completed:Ll/7i2•/L3 Well ID# 6j ft- 395 ft p-?i��j,—
.. 5a.Well Location:
Sit-la t ft. S °e �. .,m :,' '` t'
Facility/OwaerName FacfityMil(if applicable) ft'
11 14 ( F, na
3.1( ' ( , n ft. �Ur to d ay/3
.fit dZlp �a trc rot //
Physical Address,City,and Erp I 1n(:,,, :?
1 ^:s.t. ..1 t r:.l
��i'I IIIY. ,21.REt64ARK iS L3^V. ,:33 0, ,
County Parcel Identificat onNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one ladling is sumicient) 22.Certification:
'36,. 3s527 N eft 007c1 Si w k------------
c72Z/ 3
6.Is(are)the wells) errnanent or (°Temporary
Signature ofCertifed Well Contractor Date r
By signing this form,I hereby certiiA,that the well(s)nay(were)contracted in accordance
7.Is this a repair to an existing well: IQYes or No with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthisisarepair,Jllloutlarownwellconstructioninformatl° and explain the nature of the copy of this record has been provided to the well°weer_
repair under#21 remarks section or on the back ofth-slarm.
23.Site diagram or additional 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,only 1 GW I is needed. Indicate TOTAL NUMBER of wells construction details.Yon may also attach additional pages ifnecessary.
drilled: SUBIt/d1TPALINSTRUCTIONS
9 Total well depth below land surface: 3f5 (f) 24a.For All Wells: Submit this form within 30 days of completion of well
Farmuttaple wells list all depths ifdijjerent(example-3@200'and 2(100'), construction to the following:
10.Stacie water level below top of easing: y0 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"4'" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: g (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
���`/u�) above,also subunit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(ie.anger,rotary,cable,directprsb,etc.) Ii
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test: 4jTv/ 24s.For Water Simply Be Inleetion:Wells: In addition to sending the form to
// the address(es) above,also submit one copy of this form within 30 days of
I3b.Disinfection type: kill' Amount: 4.62 . completion of well construction to the county health department of the county
where constructed.
Form OW-i NorthCarolina Department of Pavimnmeatai Quality-Division of WaterResonrces Revered 2-22 2016