GW1--03532_Well Construction - GW1_20230519

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WELL CONSTRUCTION RECORD L(M-11) For Intemal Use Only: - - --
1.Well CoutractorEnformation:
Cameron Bazin 14.WAT.M ZG?ES
WellCorametorName FROM TO DESCRWi1mgI
4518-A 3� ft. I M
it. I ft
NC Well ContractorCert ficationNambw
15.0QTEILCA MG for multi-cased welts 01LLIIVS22 ifa licable
Aqua®fill,Inc. FROM To DL MY6FER THICIIBNESS MATERIAL
CompanyName O ft (5 7 ft � in.
p 16.INNER CASING ORTIIBIIdG(geothermal doseddoo
2.Well Construction Permit#: 7 01)O t 0 FROM To DL0U=- I TMCRaTss MATERIAL
List allamlicable null cmistructionpemdts re,Mr,Comth;State;Variance,etc.) EG IL 1 L
3.Well Use(checkwell use): % ft in
Water Supply Well: iZ SCREEPT
FROM TO DrAMETER SLOTSrLE THICKN.SS MATERIAL
Agricultural �Municipai/public ft $; in.
GI I I +_
eothtamal(Heating/Cooling Supply) Residential Water Supply(single) R ft. rn,
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT
Trri tiOn FROM I TO MATERrAL EMPLACEMEtNr[METHOD&AMOUNT
Non-Water Supply Well: IL 9 ft
Monitoring ORecovery & ft
Injection Well:
-. A tufer Recharge ft ft.
arge DGroundwaterRemediation 14.SAyD/GRAVELPACK da ticable
quifer Storage and Recovery OSalinityBanicr FROM - TO MYATERML rs91PLACEMENT METHOD
Aquifer Test OStormwaterDrainage ft ft
Experimental Technology OSubsidenceCoutrol ft ft
Geothetmal(ClosedLoop) E]Tiacar 20.DRILLMGLOG attach additional3lree�ifnec
FROM TO DESCRTFrIONY mIDgbadness,wiltrack e, size,etc.
NGwthermd(Iieating/CaoliagRelam) Other(e lainunder#21 Remarks)
© ft- ISa ft SUn_�_
4.1Date Wells)Completed: S L> Well ID# 150 "' U2 ft J�dC4,,
5a.Well Location: ft ft
ft. ft
Facility]OwnerName Facility Mir(ifapplicable) ft it
y
_3Vi S ft. ft
f�s`cMo1'+l �.'��t Pf i rt_ �\�+.•\�Q O�i� ft fL y � y, �®+ ��
PhysicallAddress,City,andZip
I pf5�,T� 21.RFMIATaY« _ ..
County Parcel Identificaticallo.(PIN)
5b.Latitude and longitude in degrees/mintiteslseconds or decimal degrees:
(fwell field,one IatAung is sufficient) 22.Certification:
316 W
6.Is(are)the well4ppermanent. or OTeraporary SigaidumofCertifiedWellContractor Date
By signing this form,I hereby cerlrfy that the rveII(s)uns(care)constructed in accordance
7.Is this a repair to an existing well: t)Yes or DNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
IfthisisanVairfiff out lmotmwellrnnstructioniaforatatiod and cWhiia the nature ofthe copy ofrW record has hampmvidedto the walloroaer.
repair under P21 remark section or on the back ofthisjotaL 23.Site diagram or additional well details:
8.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 well
construction,only 1 GW I is needed.Indicate TOTAL NUMBER ofwells construction details.You may also attach additional pages ifnecessary.
dulled. SUBMITTAL 1519 RUCTIONS
9-TOW Well depth below land surface: "Y2 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For muffiple walk list all depths ifdiffereut(erample-3(3a 200'mrd 2@100) construction to the following:
10.Static water level below top of cadug: U0 (ft) Division of Water Resources,IInformagon Processing Unit, .
Iftvarer level fs above coring,use+•• 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter: Ic (W) 24b For Injecton Wells: In addition to sending the form to the address in 24a
12.Well construction method- . above,also submit one copy of this form within 30 days of completion of well
(i-e.auger,rotary,cable,discetpus%etc.) construction to the following.
Division of Water Resources,Underground]Injection Control Program,
FOR WATER;SUPPLYr WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
13s.Yield(gpm) Method of test. 96 a 24r.For Water Supply&Injection Wells: In addition to sending the form to
the address(es)above, also submit one copy of this form within 30 days of
13b.Disinfection type: `✓` Amount: (Gs�— completion of well contraction to the county health department of the county
where constructed.
Form Gw-1 Worth Carolina Department ofEnvimnmental Quality-Division of WaterResoarces Revised 2 22 2016