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HomeMy WebLinkAbout_Well Construction - GW1_20230315 (61) _.._ _..__. :-. _ - 'Print 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 , a" t t r t T'ih '