GW1-2023-01783_Well Construction - GW1_20230223

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Print Form '
WELL CONSTRUMON RECORD f W 11 For internal Use Only. — — - -
1.Well Contractor luforination:
Cameron Bazin
' 14.FFlATER ZONES I I
Wcll CantractorNamo FROM To DESCRIPTION
4518-A n. IL j'
NC Well ContractorCertillmdenNumber (L I ft
IS.OUTER CASING(formulti cased;wells)OR LU4ER fif a lIrable
Aqua Drill, lnt:. :rER 1 THICKNESS MA L
Companytleme
a 16.WMR CASING ORTIIBING eottrormaldow"oo
2.Well Construction Permit#:_ ✓ �f'f FRoaI To
DIAMFIER 1I110E01ESS MATERIAL
List a►l applicable well carrstrucii_pemats r e UIC,County,Stab Vadanm eta) ft. I' in.
3.Well Use(cheekweil use): ft. f6 in
Water Supply Well: 17.SCREEN
FROM TO DiAMMR SLOTStZE THICKNESS MATERIAL
grictilttttal 13Municipal/Publie ft.
-Geothermal(Heating(Cmoi-mg supply) EIResidenkial Water Supply(single) ff in
Industrial/Commereial DResidential Water Supply(shared) 18.GROUT
I Itri lion FROM TO MATERIAL E51PLAC09NTb1SIHOD&AMOUNT
Non-Water Supply Well: & ft
Monitoring Recovery R fL
Injection Weil:
uifer Recharge ft
A4 age �GronndwaterRemediation .
Agttifer Storage and Recovery »
Say Bier 19 SAND/GRAVEL,PACIC ra licahl
:Aquifer Test 01' e
FROar TO MATERIAL EMPLACEME"MElIiOD
t ; StormwaterDrainage iz ft
crime-tal Technology OSubsidenceContol ft. fG
Geothernral(ClosedL°op) E]T.r 20.DRUAMGLOG attar addltional sheets ifnace
Geothermal(Heating)Cooling Return.) 00ther(eylainunder#21 Remarks) FROM I To DE.SCRWrION eotor,hanwess,wWruk [e-mail]
ft: 115 � GrY✓� '
4.DateWeil(s)Completed: 10 VlrelllLN€ (y' tt. 105 It. .
sa//wrell Location: J IL ft.
Facility/OwacrName �iry #(rFapphcabe) ft. ft.
�s '
h� (xm•..ems
1010 H1 11s s✓+�r� -).' r�loivl R it: — 9 ^ o
PhysicdA�ddtcss,QLy,andZip y ft. fL — L:1
/Ie76�Y/� 21.REMARXS
COSY Parcel ldentiffestionNo.(PIN) G:VQr.0G
5b.Latitude and longitude in degrees/mianteslseconds or decimal degrees:
(ifwdl ficid,one lat/long is sufficient) 22.Certification:
6.Word)the well(S) Permanent or IOTemporary Signatarc fCernfiedWellContractor ! Date
Bp signing Ills form.I hereby Berg-thai the welf(s)rsas(were)constructed in accordance
7.Is this a repair to an existingwell: IlYeS or "__ o with 15A NCAC 02C.0100 or11A NCAC 02C.0200 Wdl Conshue&aa Standards and that a
Ifthis is a repair,fitioutkwwn%VWCanstructfon informs on and explain drenatureof&e spy offt record hasbamprovidend to the aril amvner.
regal•under#21 remarbsection oron the back offir sfornt.
23.Site diagram or additional well details:
ti.For Geaprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction.only IGW-Iisneeded.IndicateTOTALNUMBERofwells construction details.Youmayalsoattachadditional pages ifaecessary.
drilled
2 ail SUBBWXTAL INSTRUCTIONS
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9.Total well depth below land surface: (ft) 240.For All Wells; Submit this form within 30 days of con Ietion of well
Formula'pleivellsllstandepdcsif�fjererrt(elamp/e_3Q20�0'andZQI00j construction to the following: Y P
10.Static water level below top of casing: [/o i
If water level is above casing;rise ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: A6 (in) 246 For Infection We F, In addition)to sending the form to the address in 24a
12.Well construction method: ro V,-ArIl nbove,also submit one copy of this,form within 30 days of completion of well
(ia angeS rotary,cable,direcrpasL,ere) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of WaterResoarees,Underground Injection Control Program,
1636Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) a Method of test: 7ii"�{yr 24c-For Water SuDDIa&lriecdou Wells: In addition to sending the form to
f r� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type; 6t Amount:����` completion of well construction to the county health department of the county
whereconstructed
Form' North Cmolina D epartmcntofEnvuonmenmlQW ty-DivisionofWaterRemurces
I llevised2-22-2016