_Well Construction - GW1_20230315 (67)

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WELL CONSTRUCTION R (GW-1} For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin 14.WATERZONES
FROM TO DESCRIPRON
tell ContractorNamc
4518-A 2�Sft fr. 5 G'�
ft. fi
NCWellContractorCerdficationNumber 15.OUTER CASING formnwI&wedwdlb ORLINER Ufa Ileahte
Aqua Drill,Inc-
MOM
FROM x0. DiAlli TM T�CHIVEss MATl1ifAL III
CompanyName
r q sT�/J 16.MERCASINGORTDBING eothetvnlclosed-loo
2.Well Construction Permit#-. 4 tl ` FROM TO nuut>rEtt put: ss hsAzrzuaL
List all applicable melt crosstructlon permits(i.e.UIC.Caanry;State Varianc4 etc) M ft In
3.Well Use(checkwelt use): fa ft In
Water Supply Well: FROMO DiAMECER' SLOT SIZE TFRCKhm 14ATERTAL
Agricultural QNSunicipal(Public % q
in-
_Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft is
hrdustrial/Commemial 011esidential Water Supply(shared) 1&GRODT
EnThrigation FROM 170 MATERIAL gptpLACBafENTIIWMOD&AMOUNT
Non-Water Supply Well: 0 ft 2-5 ft
Monitoring E31tecovery ft. ft
Injection Well: % &
.Aquifer Recharge QGroundwaterRemediation
Aquifer Storage and Recovery DSalinityBarrier �oASANDlGR�VELPACK IA'16hMLe. EMPLACEMENTrtIMOD
Aquifer Test QStormwaterDrainage % IL
Experimental Technology QSabsidenm Control ft. ft
lGeothermal
Geothermal(Closed Loop) QlTracer 20.DITILLING LOG attach additioaal sheetsifnec
(Heafiu%CoolingRehtm Other(explainunder#21Remarks) FROM TO DESCRIPTION mror.ba2 ysoltlroek a rstnsizc.etr.
n ft �%J &
n c/
4.DateWe➢(s)Completed: 1f�% WeIlID# rV c7 So KCAL
5a Well rL�ocatioow. ft' ft.
fL
FacilitylOwuerName Facility IM4(ifopplicable) R
�Ie2 71- oY o'cw GLtw6b' C.L y���.s1 tI� % MA , 1 CGCS
Physical Address,City,arift ft f,
21.RTsMA110 -.,_....... ,N
county Parcel Identification No.(PIIN `r
is
5b.Latitude and longitude in degreesiminutestseconds or decimal degrees: i n
(ifwell field,one lat/longis sufficient) 22.Certification:
6.Is(are)the we➢(s)Permanent or nTemporary SignatarcofCciifiedWellContractof Date
� By signing fh[s fori,1 hareby eerlht that trio well(s)uus(ism)constructed in accordance
7.Is tbis a repair to an existing well: IQYes or No with 15A NCAC 02C.0100 or ISA MAC 02C.0200 Wdl Conrnuc6on Standards and that a
Ifthis is a repair.JUl out known well construationinfarmatKnn and explain the nature afthe copy ofMir record has beenprovldedto the moll mvner.
repair wider 021 remarkssection or on Me backofthisform_
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or wen
construction,only 1 GW-1 is necdcd. Indicate TOTALNUMBER of we➢s construction details.You may also attach additional pages ifnecessary.
wed' SUBMITTAL INSTRUCTIONS
k Total well depth below land surface: 5 00 24a.For All We➢s: Submit this form wither 30 days of completion of well
For mukiplei volts list andepthrTfdifferent(exdmple-3(a)20�0j'and2Ql00) construction to the following.
10.Static water level below top of rasing. (ft:) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use'4" 1617 Matt Service Center,Raleigh,NC 27699-1617 }
11.Borehole diameter. (in) 24b.For Iniec ion Wells: In addition to sending the form to the address in 24a
`t—titr ,' above,also submit one copy of this form within 30 days of completion of well
12 Well construction method:
l��—,f construction to the following:
(i.e.auger,-tuy eabley dirmtpostl.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Niall Service Center,Raleigh,NC 276991636
13a.Yield(gpm) �a Method of test: St f1' 24ts For Water Sutmly&Iniecttlon Wells: In addition to sending the form to
t the address(es) above, also submit one copy of this form within 30 days of
13h.Disinfection type: + Amount:���°Iz— completion of well construction to,the county health department of the county
where constructed.
I
Farm GW-1 Notrh Carolina Department ofEnvimnmental Quality-Division of WaterResources, Revised 2-22-2016