GW1-2023-01596_Well Construction - GW1_20230214

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yELL CONS ®1V 1t3EiCORD(�J b� For7ntamatUse Only. I ;
L Well Contractorinfonnatfon.
CameronBazin 14.WATERZOMM
FROM TO DESCa(i�YIION
Wc11 Canamctntldemc tL 8• 7fl !L
4518-A it. fL
NCWe1lContmctorC7ectifiaationNomber 15.OUTER CASING edwe115 ORIi R a llcable.
FROM TO DIAMi+7ER h THICKNESS MA1E1tIAL
Aqua Drill,Inc. ,t. tw
Company'll— 2n Q 16.INNERCASINGORTUDING thernnldosed4ob
ej L FROST To DiAMEIER 1- TffiC[{NE55 MATERIAL
2.Well ConstructionPerthit& ft. fC
Llstall applicable e°ell cotuvuctlonpwn is C e-u1G County,State_parlance efe:)
ft. &
3.Well Use(checkwell use):
17.SCRLEN SL07,ST� .� MATERIAL
Water Supply Well: FROST TO DIAMEi in
'Cultural icipaVPahlic n0'
Geothermal(HeatinwCooling Supply) Resideahal Water Supply(single) IL R
IndustnallCommercialResidential Water Supply(stand) I&GROUT �r Ac$amNTMETHon&AMomvr
ltri tioa FROM TO MATERM
Non-Water Supply Well: 7
Monitoring Recovery %
Neetion wen: ft. tz
:. Aquifer Recharge �GtoundwaterRemediatioa 19.SANDiC,RAcVELPACK bcable'
gDlferStolageandRecovety DSalinityBamer FROM To MATERIAL I;taPLACEMENTME180D
quiferTest ElStormwaterDla rage
Experimental Technology E3Subsidencecontrol fL $
Geotitermal(Closed Loop) �Trt>cer 20.DRIIdiPTGLOG attathaddittoanlslceeisit
FROST TO DFSCRIP'I'ION aloe soitlack 4 etc
Geotheanal(HeatiDg/CoottogReturn Other( jWunder#21Remarks ® fL a fi: lti
%r
4.DateWell(s)Completed: VteRM# - R i}
Sa.well Location: °rw
AAA t'ly La,5 r ft-
Fac�litylOaverN Faefiity 1Db-(ifapplicabk)
�I [LA
JYtv'0a �G i�`� /pant ins?r�
I;.3u 7r
PhysicatcAddnss.C icy.andTap 21.2EMARKS
CauRty Parcel ldentificetionNo.(PIN) ,
5b.Latitude and longitude in degreeslmimuteslseconds or decimal degrees.
(fwc11 field,one Mong is sufficient) 22.Certification:
sipatureofCcoffiedWcUCoatraetor h note
6.Is(are)the well(s) Permanent or E31remporary tl at!ttie tvell(s)Hus(were)ewarmued in aaowdmtce
BY signing Ibisform,I hereby cenifp ;
7.Is this a repair to an existing wen: Elves or . No svieh 15A NCACO2C.0100 orISANCAC 02C.0209 Weil Construction Standards and chat a
fi lfthisisarepakfiUmdAnmvnwellrnnsMtcdonin atio and lain thenatrueoJthe
capyofthis record has been provided to the xrll owner.
repair wader#21 remarks section or on ilte backoffb isfo r 23.Site diagram or additional well details+
Yon may use the back of this page to provide additional well site details or well
L For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construadon details-Youray also attachadditionalpages ifneemmU-
coustruction,only l GW l is needed.Indicate TOTALNUAMER of wells
• wed; SUSMIT]CAY.YNSTRIICTYO1lS�
9.Total well depth below laud surface: 2 0Q 24a.For.All Webs: Submit fl»s'foun within 30 days of completion of well
Form�dnple welts list act depth ifd jJerent(example-3�a 200'and2((a)100� construction to the following I
Y@.Stacie water level below top of casing: (M) Division of Water Resources,Information Processing Unit,
#',vaferkvel is above caving.use"+" 1617 MIIfl SelvIce[center,Raleigh,NC 27699-1617
r: eb f n.) 24b.For Yniection WeIIs: In addition to sending the form to the address in 24a
1L Borehole dimmet
above,also submit one co of this form within 30 days of completion of well
12.Wen construction method: i"C�e't t r d construction to the follovuin 4
(i.e,auger;rota y.eMp,dimapwb,de.) I
IDivisian of Winter Resource! iJndergronnd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636IYlaa Service Center,Raleigh,NC 276991636
t �
Method of test: 5(�� n A 24c.For Water SuDDIv&Yniectio Wells: in addition to sending the f
13a.Yield(gpm) arm to
the addtess(es) above,also submit one copy of this fors within 30 days of
13b.Disinfection type: Amount: l�dE'o completion of well constntcdiori to the county health department Of the county
where constructed.
Sorts ,W_1 NomhCmofinaDWArb untofEwAmnmmtolQaality-DrAsionofWaterRewarees Revised2222016
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