GW1-2022-10087_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
1.Well Contractor Information:
•%PN` 5 Kiryq
w 11 Concoct Concmctor Name li WATER ZOMRS
TO
4 2 O D R• nauRplsgs
CJ R
NC Well Contmatm Certification Number R• R
Aqua Drill, Inc. S.OUTER CASING for maBiwed IN tnk LINER da IcaMe eRom TO
ntAMETBR THICKNE38 MA AAI,TER
Covgrmy Neme B. j� 1°' V
2-Well Construction Permit q: ^/ 16'f SR CASING OR TUBBING tlwmd dazed-10 C/
LitlaG applicable we!(cauhvctiort permnr %C,Caune�hs ToZ FROM TO mAM(geR(geothermal
Ey3 MAIRRIAL ry.Smte, t'areance,etaJ tt tt Ia.
3-Well Use(check well we):
D• ft is
Water Supply Well:
17,SCRZRN
Agricultural ®MmricipaVPubkc mOM �O nleatnst morsta sI1CRNF84 MATERIAL
Geothermal(lieating/Coolin Supply) V. R is.
8 pp Y) Brain
Water Supply(single)
Indust iaVCm inemial 01(csidentiel Water Su I hared) R it. Is.
bri lion pPY(s 75•GROU7'
Non-Water Supply Wen: FRoM To MATEauL EntruceslErrr mernon6AMoutr
Monitoring O R O ft
Injection Well: Recovmy R tt
le U
Aquifer Recharge ®Groundwater Remediatian D• R
Aquifer Storage and Recovery ©Salinity Bonier 19.SAMD/GRpyEL rACK Ikable
Aquifer Test rROM ro MATERwL EmrucrAfExr®Stormwater Drainage R R
G MEfBDD
Experimental Technology ElSubsideace CommitGeotherrmama (l(Closed Loop) ©T� D• ft.
Geothermal emi X DRILLING LOG attach addlttonal shag if mcessa
Catlin Return) Other( lain under#21 Remarks tmDM TO nrscarrttoN rams soma mmraa
tt IL ova w
I.Date Well(s)Complet��z�_��We11 ID1! C �
—�_ D- /
Sa.Well Location: O ft IV C �
R f Yo h
Faclity/Owmer Name R
rlJ (� q '7 Facility WN(ifopplicabk) (L R V ) C
�r-�-�CL'— (�?s/ f—( 1 I)/1 Z.�I yIG�n 9 t C
Phyercal Addrm c ty,and 1
���inn ern ` 2721 -2 It ft a
2L REMARKS
Couvty Parcel Iderdi6mtivn No.(PfN)
5b.Latitude and Ioogitude in degreee/minutwi ounds or decimal degrees:
(if well Geld,one!oolong is sufficimt) "30C,
22.Certification:
N
W
6-Is(are)tho we°n
() ermanent or [3Temponty 9r one ofCertifiedWitcouscoj
Da e
7-Is this a repair to an existingwell. By algning l6k fang I anr6y nrl>!Y µoil µe well s was
lfµisLsarepatr.fi(l out known well ansnvcnon Le o� or [3No wiµ15ANCACO2C.0100o ISANCAC01C.0200 Wrll Coylrucic onrSralMania and!hate
repair under 9I7 remarks section aeon ilk back oftht form, and explain µr nature of the oopY ofthis record has been provided m the ae/!owner.
23.Site diagram or
SL For Geopro only
I G -I gored-Loop irate ermal TOTAL
Welt'having R he same You may use he back of thisapagewell
toePmvide additional well site details or well
willed:on,only 1 GW-1 is needed. Indicate TpTAy NUMBER ofwells construction details. You may also attach additional a
drilled: �J pages if necessary.
9-Total well depth below land surface: ,3L SUBMITTAL INSTRUCTIONS
Formuk(o(e welk(vt all deprhs ijdru(example-3(&Z00'asd 2®100) (ft•) 24s. For Ali Wells: Submit this form
�0Q. construction to the following: within 30 days of completion of well
10.Static water level below top of casing: J v
ljwara lealkabose casing,nee"a" (ft.) Division of Water Reource info ihIon processing
6 my11-Borehole diameter: (n•) 1617 Man Service Cotter,Raleigh, 27991617
241LJ sbov For Iolectio Wells: In addition to sending the form to the address in 24a
12.Well cotstructlot method: // C) i1 I above,also submit one co of this form within 30 day,of c
(i'e•user.rotary,rabl0.directpmlr,ern) construction to the following. completion of well
FOR WATER SUPPLY Wgll I ONLY: Division of Water Resources,Underground injection Control Program,
1 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gp.O_�_ Method of tat 7'�'�
24c.For Water Suttly&I IeMi w
13b,Disinfection type:AM the addres h addhon to selling the form to
Amount. Q s(es) above, also submit one copy of this form within 30 days of
completiao rf well construction to he county health department of the county
where constructed.
Form GW-1
North Camlim Depmtmenr of 0nviommeonl Quality_Division of Water Resources
Revised 2-22-2016