_Well Construction - GW1_20230315 (61)

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WE ILL,--v� 61Limu�katurgr hiss;. ®��— - ForIntemalUse Only: ',,,
L Well Contractor Information: I.
Cameron Bazin 1a_warm.ZONES
FROM TO DESCRIPTION
Well ComacmrNamc 459 8-A 7� ft. R CJC7
ell fit
R. ft.
NC WellCaahactarC tificalionNtuaher — t7
Is.OUTERCASING(formalti-eased.oells)ORLRNERCd'a nimble) 1
Aqua Drill,Inc. rum t TO, ft. nlaa>El,>rcm. r�
ereass MATERIAL
1CompanyNnme j•
16.INNEER 7CASI GORTUBI dG(geothermaldosed-loan)
2.Well Construction Permit#: . ! q8 2 FROM 70 DIAMETER 1 SffiSS MNrERur.
• List allapplir-able well tattsnuctionpermits f e.Ulf Count'.Stare;Variance,etc.) ft. ft.
1.1
3.Well Use(checkwell use): ft.
to
I Water Supply Well: 17.SCREEN � MATERIAL
FROM to DIAMETER SLO s'srr�
1 �''_"cultural OIunicipal/Public it tt fa.
i •Geothermal(Beating/Cooling Supply) i g,Residential'Water Supply(ogle) . th ft in. •
Nil Industrial/Commetcial ii.Residential Water Supply(staled) 10.GROUT
;Irrigation FROM TO • -MAIER00. Eesuc:EMENE EmOD.0AMOENT
None-Water Supply Well: 0 25 ft (21;94
*'Monitoring DRecovery IL ft ,
Injection Well: ft ft
•Aquifer Recharge DGroundwaterRemediation
19.SAPID/GRAVEI.PACK cif �e) yaRg-rgOD
M;Agnifer Storage and Recovery DSalinityBamer FROM TO
Ill'• . -er Test EDStomiwate'Drainage IL It
111 Experimental Technology 0 Subsidence Control ft. ft.
M;Geothermal(Closed Loop) OTmrer 20.DRILLING LOG(attach addium nl sheets lInecessarY)
o ro DESCRIPTION(color.bacdarst.sni0caekOpe,g fin cte)
;;O•Geothermal(Heating/Cooling Return) nOther(explamtmder#21 Remadi) �/1 ft �j5 4l/)cL,
3/G. ft-4.DateWell(s)Completed: 7 Well bID# rj /,�D7 > V�/rl I
t / ft. ft
Sa.WeULocetion:
•
Facrifty/OwoerName Facility mDit(if applicable) ft. ft
-3 Oz4 41 . Le Sig(? Lin )/i/r\li;r- ll((G ft n
ft. ft.
Physical Address.City,ancIZIp 41r ;i ) tut
2.RIIKARISybdlk ;-\
.
Coimry Parcellderi i0marionNo.(PIN)
' Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
-
(if well Bctd,one Int/t®gis sufficient) 22.Certification:
. 6 i' Mi rl ga 57572.2 w 7,//Z
Stamm of effifwl Well Contractor Date
6.IS(are)site Welts ermaaent Or Ea7 emgorary urn t Re math,that the wrW(s)ii (mare)constnwed in accordance
wi.rim:a I,m. 0 by
�. XeS o No with 15A NCAC MC.0100 or 15A NCAC 02C_0200 Well Construction Standards and shot a
I 7.Is this a repair to an existiig a ton and the nature of the
copyof this record has Urn provided to the well Ol@Ier.
"this is a repair,fltl outImown well construction iajeslamn
repair raider#2!remarks section or on thebactcof figs form 23.Site diagram or additional well details:
Wells having You may use the back of this pagesto provide additional well site details or well
S.For Geaprobe/DP T or Closed-Loop Geothermal �mells
construction details.Youmay also attaclradditioaalpuges ifnacessary.
'constraction,only.1 GW-1'isneeded.Indicate TOTAL NUMBER of we SpgNiYTIiALINSTItUCT10NS
dulled:
below land surfat op (ft) 24a,For.All Welts: Submit this form within 30 days of completion of well .
9 Toro➢w�depth ie 3 o and 2 fight) construction to the followin
. For multiple wells list if different(tourmp - �.� g'
(e, (ft) Division of Water Resources,Information Processing Unit,
10.Static water level below top of r�nzng: 1617 Mail Service Center,Raleigh,NC 276991617
"water lava!is above casing.use --
(in) 24b.For Injection Wells: 1a addition to sending the form to the address in 24a
12.1Soreboie diameter: above,also submit one copy of this form within 30 days of completion of well
fly Well construction method: t (�`/J{)� construction to thefollowing: i.
�,�m,ga rotary cable,dinar pffih,cm) Division DF Water Resumers,Underground InSestiuD Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636 '
FOR SLIMY WELLS ONLY: 1
t r 24c.For Water Supply&Injection Wells: In addition to sending the form to
method
°f jes� the address(es) above, also submit one copy of thin; fmm days of
13e.Yield 1gpm1
Amount: completion of well construction to the county health departmentwithin of th30 e e0unty
lab_yns�feetitou type: where constructed.
North Cruolim pcgruturnt of Environmental Quality-IJ-rvirion of Wafer Resources fool GSW1 Revised 2 22 2016
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