GW1-2023-01253_Well Construction - GW1_20230127

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WML CONSTRUCTION RECORD LEM J� ForintematUse Only: - - --
1.Well Contractor Information:
Cameron Bazin 14.WATERZONEs
Wdl ComraMorNanlc FROM TO DESCRn'rhON
EL f
4518-A yZS ( ti
a
14CWdiContractorCettificationNimber 1S.011TERCASING formulti�edvieils ORLINER(,fa lieatilb)
Aqua Drill,Inc. FROM TO 11MMEM'. THICKL M MATERIAL
CompanyName
D ft. 3S ft (/�
,,{{'�, [i 16.Il�II�RCASIIdGORTI3BING thermaiclosed-loo
V 2.Well Construction Permit#: 3 o 7 Z- FROM To D t THICKNESS MATERNL
List allapplicable well canstnrctfonp—its(r-UIC,Caag%Stara Vadanca eta) & ft 10
3.Well Use(check well use): it: M io
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER IsLOi'SIZE I MHCKNM MATERIAL
DAgdcultural ft D: in
Geothermal ftatinglCooling Supply) PfResidential Water Supply(single) ft. tt In.
IndustriallCommercial / )Residential Water Supply(shy)
18.GROTTti'
i 11tri ation FRo111 I TO hLXTERIAL EMPLACEKENTMEMOD&AMOUNT
Non-Water Supply Well: © 2 Y r
Monitoring Rewv ry tL tL
Injection Well:
AquiferRecbarge []GroundwaterRemediation
Aquifer Storage andRecovay DSaliaityBatriex FROM I �vEI.PACK nATEMLe ENIFLACEMENTME ROD
Aquifer Test 0StomhwaterDrainage n Q
Experimental Technology OSubsidence Control % $
- Geothermal(Closed Loop) OTiaeer 20.DR1LLiNG LOG attach additional sheets if mere
FROM TO DFSCRM ION color.bmdnzss,saittroek size.cte.
Geadtetaial(HeatinglCoolingRelum -0tu ( hdnunder#21Remaft) f
4.Date Well(,)Cotupleted: M ft.S .-- t
5a.WeIlLocatiom R' c .e 50 P, .i
ft. JFL
2023
FacOity/Owoa m Nae r ' Facility ID#(ifapplicable)
it .
�g y ©U, L4o0x5rCh rd. i4of ANa' n info maj ^sl PrDcN:2 a 1, is
PhyscalLAddmss,,Crity,andT.ip �—
E4 it INAMMOG
! G;-Cgi 21.110 ARM
County r Parcel IdeatificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll Hold,one latlloagis"sufficient) � 2L Certification:
J6• 3 1V 1 (7. r2(, Q w
6.Is(are)the wells ermanent or 13Temporary Signat,uc o Cec6fied WeuCoahadcr Date��
By signing this form,I hereby tend-that the ueff(s)was(here)contracted in accordance
7.Is this a repair to an existing well: E3Yes or __ o iviilr ISANCAC 02C_0100 ar 1SA NCR7 02C.0200 Well Construction Slandardr and that a
Ifihisfsarepair,Jltloutlaaivnivellconstructioninformat' anderpfafnthenatureofthe eopyoffWrecordhasbeanprovlded'O&@cuvnmmer.
rovirander#2l remarbsection oron the bockofthisfornL
23.Site diagram or addiitional well details:
S.For Geoprobe/DPT or Ciosei!4.00p Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction.only IGW-lisneedcd.indicate TOTALNUMBERofwells constnictiondetails_Youmay also attack additional pages ifnecessary.
S[UBMr1TAL DMTRUCTIONS
9 Total well depth below land surface: S ( ) 24a.For All Webs: Submit this form within 30 days of completion of well
Formtdaple ivells list all depths ifdiffmni(-ample-3Q200'and 2@100)
constmctiom to the following:
10.Static water level below top of easing: �b (ft) ]Division of Water Resources,Information Processing Unit,
Ifivater level is above azsfng use+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter. (hL) 24h.For Injection WeIIs: In addition to sending the form to the address in 24a
12 construction to the following
Well construction method: �Gt�]/ above,also submit one copy of this form within 30 days of completion of well
0 e.ause,rosary,cable,ducapush,etc.) ��`—T
Division of Water Resource%Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
139.Yield(gpm) Method oftest C 24c.For Water Snnnle&Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction di the county health department of the county
where constructed.
Form GW-1 North CamlinaDepattment of Eaviw mmtd Quality-Division of Wat=Resn=es Revised 2 22-2016