GW1--03355_Well Construction - GW1_20230515

vvizu,',.. -,,&y.-.....„..1. -,fit,-, ,,;(ii-e.,,„, -,,-,-,.:-. )e,fi,i,--,s,, feif ' ,, 1,1iiiiitaa ils''.'tolii'jr-'-.--. ., ,., , 7''—ff--- --
, .
I.Well Contractor Information: . . • "Cameron Bazin
Wall CorttrartorName
. 325 a: '''ft • •fr
4518-A .
-'::44,„,•,-,' .. ' . . . '
---f--.- , _
NCWell CcmirecurrCertificotionNmnher.
IS.0111'ERCASING(thimtalti-cotisluells)ORLINERff• limb/0 - •..••,;.-". -
Agtia Drill,Inc. fROASI -. TO : , own=; •-,-TWOCEMESS"
• 0'6"., c,5';'-lt; . C'„- in-:-
CompanyNama
2.Well Construction Permit#fi -7 I 1,`4/ 16...ENEReAsEquoirround65.14.614 .---_z.-- .-.-, ---•
•
List all applicable we I I eansessettan peintits(i.e.WC Cotath:Sta(e,Variance.eta) ft
3.Well Use(cheelc wed use): . ,„ , • .• . - . ,
qa:r Supply Well:
FROM TO IMAM=_:stursuu _TRICKNESS MATERIAL
-cudhual (3MunicipallPublic it • it In. ';',. : - , - ' : • , -
.0-Geothermal(ReatingPCooling Supply) ,•*-4 ResideatialWater Supply(single) ft. ft.
4IndustrialiCommercial
. Irrigation FlisOM T3 - .MALTERIAL' . EMPIACTRORIT METHOD&Amoterr
tiANon-Water Supply'Well: , ft'' 2g ft.' ' ',/,c' - - '- • '''' :- 1-• .- -- '
Monitoring
pRecoveryft
Injection Well:
•:. golfer Recharge
•
"OGroundwaterRenindation.
19.SAIXEP/CRAVELPACK fif aPplieablei..- •'•-" ''•- - - : - " ''
i LAquifer Storage and Recovery 'ElSalinity Binder
• Aquifer Test E3Storrawater Drainage ' ft.
_ . , ,. - • __.
. ; -...."r=ental Technology E3Snbsidence Coninal , .. .
, ,• • -. -..„
Geothermal(Closed Loop) '1.21Tracer 20.DRIELIING LoG thtteeb..- addidonal Sheets KeicconsrY). _ .- '-• - ..
FROM, - 'TO' ".-..- MOIORIPTION(dolar,bradawl,sellftnektiva,grain 51212.ma:''' :. ,„ "
-73Geothermal(HeatingiCooling Reheat) nOther(explainunder1/211temants) .. - - .-- -.--. - •-., •- ' , ': '- • -• - '' • ''- - " •
.'0 1,*:•,40..:' -1-!' •"• . - '':'"-!:- ••• =-•' - - .= -:-: ..-' ' •
. . .. -.. ,
4.Date Welt(s)Completed: 072 r WellEDS 50 !r-' 62:6,!.L.,:,, .r...,0:-,-*-,':..,.'..•• .. ,- - --.., _, . i: . ,. - : :
.-.12.-, • ,.• ,,:It',1 ....::, .-...-,,-.:- ...:-... -. • -_, •-...;,-:,... ' -. - ,.,- ,
. Sa.Well Location: .--. . , , - . _ . • .
--pgsie-CA keeil -
_ . • -- . . • . • _ .
FactinyfOwnerName Fatality WO(if applimble) - it• -. .15t- .7 .- ''';' 'Pz:.b-*.-77-A''-Th i_7, :-.•:, $.;--7;•;‘•.•.:
4165' 114/ '1 A/1//ij 5071-- 6 .
a. ir.• . . .. . .. ..,..
Physical Address,City,andETp ,MAY 1, 5 2n2,q
Ye4• •
Lcin - • •xt.11031ARKS - _ _ ,
In n
acel tffratt . PCurl:-i-, .., .
•
County PIdmaenNo(PIN) •
.'
go.Latitude and longitude in degreedneinuMiseconds or decimal degrees: ' - •• .
- • •
•
(ifwell field,cam Inflong is mificfmat)' 22,Certification:
`36 25 20-3 N Sp /t4 771 g
•
Sienntnre of Cznified Well Centrador
6.Is(are) J(s)Qfennaflent• or Ekremporary
By signing this form-1 hereby avg.that the ygell(r)MIS iiwse)constructed b anconionce
•
with 7.Is this a repo_ to on existing wen: cifes er Oro coith 15ANCArecarriC 02Es.Obeen.100 or.prowdealSA NOth i dteC(LC 1.02:vaerti117:ell Constreetio dsn Standar and that a
irs a repotr,Jill out bum:will 4:mediae& terinnation ant 1 erplaintherteerre oftfte 132 ethis
.°& i
' ando-021 remarks-se:donor on the back of thisfitmt. 23.Site diagram or additional well&thaw
• You may use the back of this page to plOvide additional well site detaSor s well
3-For b,e/DPT or Closed-Loop Gstothermal Wens having Mc same
construction details.You rimy also attach additional pages ifnecessary. .
'on,only 1 GW-I is needed.Indicate TOTALNUMBEEL of vigils
dulled: SUBMEITAL DISTRUCIIONS
0 5 ,
depth below/and surfs= (ft-) 24a.For All Welk, Submit this form within 30 days of completion of well
9.Total well . -
For reads&was tfrrailikpag#.&..re.nt fraimP
te.-3®200.and 2((p1001 construction to the followilw
VO • (ft) •
Division of Water Resonrces„Information Processing Unit, . •-
10.Stale water level below top of casing:
1617 Mali Service Center,ItileIgh„NC 276394617
Iftumter level is(dime cash tg are +
24b.For_InicelIon Wells:,In addition to sending the form to the address in 24a
1.1„Borehole diameter: __ __(.----.Cm)
above,-also submit one copy of this form within 30 days-of completion of well ...
--, •
.
Well construction method: -___---- /--------(1•91- constanction to the fogowinF
(ie.anger,rotary.cable,directpusb,etc.) Division of WaterResources,Underground Injection Control Program,
FOR WATER.SUPPLY WELLS ONLY: . 1636 bliel Service Center,Raleigh,NC 29699-1635 - ..
/66ti<ex- 24c.For Water Snondv&bring=.Wells: In addition to sending the form to method of test
13a.Yield(gpm) the address(es)above,also submit one copy of this ft=within 30-days of
Araounfz___ _ completion of tewa.ell construction to the,county health depadment of the county
f1-2-
,3,,...„ oi, ,,g —ect,-, _ __Y__It____-7-
,
Natatozugna r warfront ofEnviru amectul QualitY-Division ofWaterResonces Revised 2-22-2016
Fenn GW-I
• . . .
. '
I •
-$7,m7-7,7,7,.---4.:.,.i.r....71-„ - . -
!„-,-,7„,..-.1-„: 6.,-..- ,-„...,,,, ,i..r. -•-• •,... __. •
7.4.0......4.4f-:, IVIZTAITraggig.L-1;&).4.:7:31•r.:1-...e.r...-:,',.....i.,.;-21-v.,7 r..,.7ji-'_.„.:-.'t'e,;.,',,.2::,:21;'1".."LS:1,-...,,,;:,,,,41:4;,.,..I::,111211.1.1; *::.''...,'''...f.'"1 ::7,1 '1::::.14,;:7;:':L.', F, "•