GW1--03554_Well Construction - GW1_20230519

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WE C®IaSTRUMON RECORD QGW 1) ForinternalUse Only. —
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1.WeR Contractorinformation:
Cameron Bazin 14.WATFRZONES
Well CotaractorName FROM I TO DESCRIPTION,
4518-A AS
NC Well ContractorCerf cationNumber 15.0UTERCASING ormulti-cased wells ORLINER d a livable
Aqua Drill,Inc. rRonf zo DIA6tSTER reaclaysss btATERu1L
CompaayNome
ti to in. 1c
I ( Q 16.INNER CASING ORTIIBING(genthermaldosed-loonl
2.Well Construction Permit#: FROif To MAMMA TIRCMESS I MATERIAL
Last all applicable well construction permits(i.e UIC,Count};State,Vhdanc4 etc-) R• &
3.Well Use(cheekwell use): R• fL in.
Water Supply Well: 17.SCREEN
M TO DIAMETER SLOTSIZE THICKNESS 51ATERTAL
Agricultural omunicipwftlic & ft in.
Geothermal(Fleating(Cooling Supply) esidential Water Supply(single) FROM tZ ft. ➢a.
Industrial/Commercial , Residential Water Supply(shaied) I&GROUT
i L-liggtion. FRObt YO MATERD4L E?ifPLRCEa'fENT METHOD&AMOMM
Non--Water Supply Well: fL it
Monitoring DRecovety ft: ft.
Injection Well:
f4
AquiferReeharge 00roundwaterRemediation ft
Aquifer Storage and Reco ['^Sal 13artier 19.SAPID/GRAVEL PACK if a lieable
E.-1' kitY FROM TO I bUTERIAI. I RNIM ACEMENT METHOD
Aquifer Test OStommwaterDrainage n• &
Experimental Technology QSubddence Control k arer ft-
Geothermal(Closed Loop) OT 20.DRUJANG LOG ottnch additional sheets if necessary)
ting(CoolingReturn) MOther(ex lainuader#21 Remarks) cO-big CTO D�rxWFUMON color teudnc9.sowrock % c3tesize etc.)
`J &
4.YDateWelB(s)Completed: WellMff 2-3
5a.Well Location: ft.
� r
Facli /OvrnerName ' ft. rt.
tY. Facility IDO(ifapplieable)
list )ICIJ ty;t MAY 1 9 2023
Physical Address,eity,and zip -� ft. fL
SA'A�'t' 21.REMARKS IP.Lie ... !a•r.
County Facet Identifieaticallo.(PIN) v
5b.Latitude and longitude in degrees/ndautes/seconds or decimal degrees:
(Ewell field,one lavlong is sufficient) 22.Certification:
tZv�� N g S 7(9*-- W
6.11s(are)the well --anent or IOTemporary Sigoammo£Certified Well Conttactor Date
By signing this form.I hereby rer66,that the 1-14(s)uus(were)coAwmded in accordance
7.1s this a repair to tin existing well: []Yeg.oroko with 15A NCAC 02C.0100 or ISANCAC 02C.0200;Yell Construction Standards and that a
IfUus is a repair,fill out known veil construction informatio and explain lGeaalum ofthe spy offs&record has been provided to the vxHawner-
repair under 921 remorlasection or on the back of tltisform.
23.Site diagram or additional well detrtils-.
B.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 IGW-I is needed. Indicate TOTAL NUhMER ofwells consuuctiondetails.Yon may also attach additional pages ifnecessmy.
' drilled:
SIIBMMAL INSTRUCTIONS
9 Total well depth below land surface: 2—S 00 24a.For All Wells: Submit this form within 30 days of completion of well
Farmuhrple wells list all depths ffAfferent(example-3@200•and 2@100) construction to the following:
10.Static water level below top off easing __/" (ft) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 24b.For➢niedion Wells: In addition to sending the form to the address in 24a
12.Well construction method: }��� J above,also submit one copy of this form within 30 days of completion of well
(Le.auger.rotary,cable,ducctpr>sh,etc) Construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
` 1636 Marl Service Center,Raleigh,NC 276991636
13a.Yield(gpnt) �b Method of test:�l r GI(� 24c.For Water Suavly&Iniection Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of
13b.IDisinfection type: Amount: ��f_- completion of well construction to the county health department of the county
where constructed.
Form GPI--1 North Cmnliaa DepaAmeat of£uvimn=Ud Quality-Division of WaterRescuums Revised 2-22-2016