GW1--03335_Well Construction - GW1_20230512

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M�Q:®I�IS�1tT�g N REQOR➢(�11) ForIDtefnalUst;Only_ -
I.well Contractor Information:
Cameron Bazin MWATERZONES
Well ComractorName FRODY To DESCRIPTION
4598-A AS t
NC Well Contractor CertiGratian Number
15.011M,CASiNG(€irmoltt-cwed wells ORLINER da licable
Aqua Drill,Inc. mom To DUINEI'ER TalcStvEd MATERIAL
CompanyName
16.INNER CASING ORTfJBING eothermaidoseddoo
2'Well ConstractioRPermit#:__ �g�� FROM TO rco M01E THICH MS t MATHRUL
List all opplicable web catty-wonpemats(i.e.UIC,Count};State.Yarianc4 eta) it tt In.
3.Well Use(checkwell use): fL M in.
Water Supply Well: 17.SCREEN
FROAT TO I DUM=R I SLOTSiZE I TlIrwwF s I mATERTAL
Agdcultnral [)Municipal/Public ft.
Geothermal(Heating/Cooling Supply) i3keidential Water Supply(single) % fs 6n
Industrial(Commetoiai Residential Water Supply(shared) I&GROUT
21irigation. FROM To X&TEPS" IMIFLACEltTSW AWWOD&Amoun-r
Non-Water Supply Wen: % ),5 IL Gt
Monitoring , Recovery tZ .
Injection Well:
A uifer Rech Itft.9 �e �GroundtAaterRemediation
Aquifer Storage and 19.SAND/GRAVELPACK da Rcuble
Recovery E3SalinityBanier FROM TO I EMMACEMM-MEMOD
AquiferTest DStormwaterDminage fL ft.
Experimental Technology OSubsidence Controlft R
Geothermal(C10sedLoop) ElTrd= 20.1)RILLINGLOG attnch additional sheets fifnec
NGeothermal ffleatMWCoollng Return) 00ther(explamunder#21 Remkj)
FRoM I To DESCRIPTION mleghardnzs%sotvrac{ a s"eto)
c7 � o � -tid •
4.[bate Welts)Completed:'Well ID# 9O ft
5a.Welt Location: %
iq It.
FacilitYlOwn}e�r,Nam/eC P.MW 1Dp(-ifapplicable) fL 4T_'b �'� i ;
tt: St Z �a m�ie.-!16av 4 •.•m..•.
Physical Addrms,Ctt},andZip % ft. MAY 1 2 Z023
5rt-oYz< 21.REMARKS
County Parcel IdentificationNo.(PIN)
3b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
[fweR field one laillongis sufficient) 22.Cer'tidication:
w Yiz«
6.fs(are)the we➢(a etTaaneat or OTemporary Signature ofCartified Well Contractor Date
By signing this form.I hereby cerrtfp that the ueU(s)nus(nere)constructed in accordance
7.is this a repair to an existing well: i3Yes or ._. No with 15A NCAC 02C.0100 or15ANCAC 02C.0200 Wdl Construction Standards and that a
IfIIas is a repair,fill out Imown ive0 construction informa•n and erpWa[tie natureofthe copy ofthis retard has berm provided to the wrll etvaer.
repair under#21 remark secdou or on the bark ofthisform
23.Site diagram or additional well detar
S.For Geoprobe/APl'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 I GW--1 is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessary.
drilled:
SVBAU7 ALINSTRIICM0XS,
9.Total well depth below land surface: LS (fL) 240.For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells list a s R depth ifdifferent(erampla-.q(a)200'aad 2 aQI00) construction to the fo➢owing•
ill.Static water level below top or casing.- y© (fL) Division of Water Resources,Information Processing Unit,
Ifwarer level is above cusiag.stye`�-" 1617 Rllajl Service Center,Raleigh,NC 276991617
11.Borehole diameter. (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: p Q l��y✓�j above,also submit one copy of this fort within 30 days of completion of well
0-Tinges;rotary,cable,&.1ptsk rye.) a construction to the following:
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Underground Injection Control program,
/ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l s !Method of test: ie G 24c.For Water SuDDIa&Injection Wells: In addition to sending the fort to
the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:_ !/, �- completion of well construction to the county health department of the county
where constructed.
Form GW-I Nam Carolina Department of Envimnmentul Quality-Division of Wateritwources Revised 2-22_2016