GW1-2022-09043_Well Construction - GW1_20220926

ln For
For InterntlI Use QnI
WELL CONSTRYT r>torl xEcoitu cGw-1)
1.Well Contractor Information: _
Cameron Bazin 14.WATERzoNFs
To DESCRIPIraN _
Well Contract�rName fL rt e"
45113-A ft. ft.
NCWellCuxtmctnr Certification Number 15.OUTER CASING far MUM-C sedrrells OR.LINHR R tiesble
FROM TO
DIA rrER E88 MA
Aqua Drill, Inc. ti t,�V ft. rt
Company Name 16.INNER CASING OR TUBING elated-loo MwTP-irr�'
(� FROM TO DUMUMEP. frDt7Qr1`�
2.Well Construction Permit#: t�Q y M ft.
List all applicable raell eo+ulruclion perraii,(z e.m1c2amtY.State, err-m etc)
3-Well Use(check well use): RTw rERIAL
17.Water Supply Well: FROM M TO DiwlYIErER si yr sr2x TtnctrNess
Agricultural OMonicipamublic fL ft
Geothermal(Heating/Cooling Supply) Eaf-csidentitil Water Supply(single) ft.
Indus,.naUCnmmereial "o"esidential Water Supply(shared) 18.GROUT S y„ w err Mot"Don&wMoUNT
Irri tion f TO fL
Non-Water Supply Well; FROM
Monitoring Recovery I
L ft
Injection Well: 2
q i:Recharge OGronndwater Remedtatlon 19.SANDIGRAVEL PACK stwrext�te FMry e�rfrrrr tvr6Ri013 i
Aquiferw
Storage and Recovery Salinity Baer FROM fL To ft. l
AgrrifixTest OStomrwa m Drainage Experimental Technology E)Subsidence Control ft.
------ siu.e, t
Geothem3al(Closed Loop) Trace FROM
IJI(G LOG attach addihaad 9hNrmRII6����
FROM TO DFSCR
Geothermal(Beating/Cooling Retum) noilia(explain under#2l Remarks) ft. ft 2
fL fL ��•
4.Date Wells)Completed: 1Y - -WeU rN R —
ft.
Sa.Well LA"tion. (}�(yip fL ft
IA r\ \v
..��F.R /fir FacilityU7#�faPAlitabk) i
" R i I
Physical Addrtss.City,and Zip n.REMARKS
L+
lV//4 y+. -----
I'arcelldertti5cationNo.(PII�
County
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees- 22.Certification:
{if U field,o� rs sufficiad) ��� — Q
F5. 97,t $a NY _ 7
N Date
sigaammat U.01.110a UCan7aUor
6.js(ue)the welf(6) pe(ntaD ent or E3TemporarY gy signing this form.I hereby COTO.that ill,well(,)wns(were)constrvcled in accordance
w;d�ise NC.1C o2C-oron or ISA NCAC 02C-0200 Well Conadvrtinn Standard,and that a
to an posting well: E)Yes or ppp���ff..���,,,n Copy of this record hat been provided to the-ell atmer.
7.IS dds a-Taar n in arnW,.o d lain die nalum of the
Ilthis is a rrpalr l'u°t`r k^pjT—a�mrrauia I exp 23.Site diagram or additional-cH details:
reprrlr under#21 remaris section or on the back ojUris farm.
You may use the back of this page ter 1provide additional well site details or
well
pl or G9otred-LoMr li Geothermal Wells having the same constru on details-You may also attach additional pages if necessary.
g.For Geopro 1 GW-i is needed. hidicde TOTAL NUMBER of wells
construction,only S B MITTAL gJSPRUCT10�1S
drill 1,_=_(fk} 24a.For All Wells: Submit this form within 30 days of completion of well
�.Total well depth below land p1e 3�@1001 consWcOan tnthc fnllowiDg:
Far mule plc reee&Irst afl dap r j ^ //D
Y (ft) Division of Water Resources,information Processing Unit,
16.Static wader
level below tap of caaulg. 1617 Mall Service(,enter,Raleigh,NC 27699-1611
1,j,W,, u oboe cvsrn&�� (in.) 24b.For Ini_ ec itm Well In addition to sending the form to the address in 24a
11.Borelwle dmnaemr' ..) above,also submit one copy of this form within 30 days of completion of well
construction to the following
t131-YJCld(9Pm)
well constrreetion metl'° de.)
Division of Water Resources,Underground Injection Control Program,
r,mtuy,cables dim Push' 1636 Matt Service Center,Raleigh,NC 27699-1636
ATER SQpgLY WELLSONLY
�J / '
I 24c.For Water SuPPAY&Injection Wells: In addition to sending the form to
/�p lyleiilod of test: the addresses) above, also suhmiit one copy of this Form within 30 days of
. completion of weU constnrctim ttsthe county htalth department of the county
Amount: where constructed-
. eetiontypt'
tell Division of Water Resources Revised 2-22-2016
K�Carolina Department of EIIviroDmen Quality-