GW1--04112_Well Construction - GW1_20230623

L. fin t F o )
'WELL CONSTRUCTION REC I RID( 11 For l al Use Only: -,. ?, ' P�
1.WeJ Contractor Information: .
Cameron Bazin 14.WATERZONPS .
FROM TO DE59RnCreatt.
Well CrIhILu Gel Name --
4518-A a . __'P?
NC Well eoelractor(kstifrmlionNambet 15.01)TERCASTROfferamidtmedwells)ORL1NERO ble)
IROM TO DIAMRTKR
Aqua Drill,Inc. � � � .TRIMNESS MATERIAL
Compatry'plasne D_. .. 65 p
py) 16.INNERCASING OR TOEING( them�aidmerbtoap)
2.Welt Construction Pitt to Q I (� FROM. ;TO Dins ae¢auaESS MA•ER/AL
List all linable well ocean ulaaft It;, tn.
apP permits(ia all;Cotmh:Mel Yarlmroe.eta) ..
3.Well Use(clteakweli use): ft. ft. In.
Water Supply Well: 1Z SCItEffid - •
FROM •'TO .DIAMETER SWFte'IZE TRIM MATERIAL'
a .:cultural Daft
iclpatipnhlic ft. ' 1L is.. .
ii,Geothermal(Beating/Cooling Supply) 4` Residential Water Supply(ogle) it. ft. to ; .
�tIndustdallCommetcial Residential WaterSupply(slimed). is.GttODT . .
t 3III]gation FROM .-. .TO. MATERIAL EMPI ACI!MENT SEIROD&AMOUAT
Non-Water Supply Well: !J R, ZZ ft• hies
7li+Monitoring DRecovety ft. ' ft. .
Injection Well: f .
i • 'Ter Recharge - DGmundwaterRemeSation ..
19:SAND/GRAW PACKfdnentiemate) -
i t Aquifer Storage and Recovery OSaiiaity Barrier FROM. TO •- . DIADIRIAL EMeLActih ENI METHOD
t' • - Test 1:3StmmwaterDrainage fL .ft
'Experimental Technology SP1xia - Control h ft •
*Gind(Closed Loop) °Traces To.DRILLING LOG(amsLaadiHoml duets ffneeesmsy) ...
-FROM TO D�CRIPItON(m7srkadam,mNmk17D-m4'1B�em.)..
Geothermal(E[eatirhglCcotlugRetun) �OHter(explaurffidet621Remaiks) ft. 60 - ,
4.Date Well(s)Completed: 4//6/Z l WelI IU# &) ft. 3vs /26. Lt,
Sa.Well Location:
rr(( r -„ :
NGc�t�nGnl polo-let Q4. L .i ...t_ e �'
Seeility/OwnerName Realty (if:indicoble) R. Et.
,jkaS kart, • ,� JUN Z023
A and tnA� ::n P:; t
Physical Crty. TP ys.. um
•
1ti1'(kd7 LLISSI1AR1(S :°a :µa
County Parcel!dwelteationNo.(PIN) •
Sb.Latitude and Ioigiitudeia degrees/minutes/seconds or decimal degrees: CertifieaHon:
(ifwellfield,aae biking is sufficient) 22.
. l3� 11 lv Ni2vg5 EY wC/./(242!?.____ .
Sigco -fled Well contractor
6.is(are)the wells r e i�•ermaneset or empor ary
By signing this farm•I hereby crab.that the nettle)am.(acre)constructed in accordance
b eristing we>f: �Yrs or No With ISA NCAC 02C.0100 or ISA NCAC MC.0200 Well Construction Sta2rdmds.and that a
7thisiWs arepoir PJ lnt eaatareofffie copy ofthis record hosbeenprovided1otheavl&waxer.
ifthi:is a r fill out/atovm hell cm emir ioit iaformatr had epla •
•repafr under#21 ramarla•section or on Mabaek of lids farm. 23.Site diagram or additional well deta
belAl?r1• Ciased-Loop Geothermal Wells baying the same You may use the track of this page to provide additional well site details or well
g.7F®rGeopro coastmcliandetails.Yon may also stmch additional pages ifnecessary.
consrardim ordy1 GW:I is needed.Indicate TOTAL NUMBER of wells
drilled SUBMITTAL INSTRUCTIONS
9.Total well depth below/and surface:_ 3`15 (ft.) 24a.For MI Wells: Submit this fora within 30 days of completion of well
Far multiple ivelts list all depths afeltyment(aample-3WD'and 2(010t1) construction to the following:
11 Static water level below top of easing: (a.) Division of Water Resonrces„Information Processing Unit,
rower level is above casing.use-+" 1617 MalServtea Center,Raleigh,NC276991617
11.Borehole diameter: / (In.) 24h.Ator laiection Weds: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: $,? r contraction to the following:
(le-auger,rotary,cable,directpush,etc.)
Dlvislon,of WaterResources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service.Center,Raleigh,NC 27699-1036
13o.Yield(gpm) .0 Method tritest: J1 1i`
s l 24c.for Water Surely&Iota: ton Wells: In addition to sending the form to-
I the address(es)above,also submit one copy of this fort within 30 days of
13b.Disinfection type: pit Atnotmt: 6n t-- completion of well constmction twIthe county health depsitment of the county
where constructed.
Form GW 1 Narth Carolina DepartmentofEnvironmentalgo*-DivisionofWaterReseaces • Revised 22z-20t6