HomeMy WebLinkAboutGW1--04123_Well Construction - GW1_20230623 41
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WELL Chit'$ ]VILktMa` k:ttixifll t tally=Ay"- -PatlIttit1101O et try ----- — -`..__._3. . : " .----'4 '
1.Wef Contractor YaformaSion:
Cameron Baziil 14.WATER ZONES
WellComraatorldamC FROM T0. DESCRIPTION
4518-A 26.2 ' D. '�' ,.t ,.1 i,
n. re.- 'f
NCWeB rout:Pr:or CerticarationNomber 15.otriu CASING(for maUI. ed weila)OALINSR CH' le)
Aqua Drill,Inc. FROM- TO DLk6>EIER IMCKNESS MATERIAL
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R. ys fr. in. ' pU/.
We yName 2. ( 16,INNER CASING OR TUBING(emtbermil elosed400P)
W�Construction PeEffiifC#: ��/(f PROM To ' DIAMETER MUCHNESS MATERIAL .
Um all applicable at:l existructionremits p e UiC.CouvW.Stag Yarimec4 do) fG ft l
3.Well USE(cheellwg[i use): ft ft; in
Water Supply Well: 17.SCRIM
FROM TO DIAMETER nos'sax T'NICKDISS MATERIAL
cultural OMmmicipallPublic ft FL ISCr�thcmol(]iea11n/Cooling Supply) 'delta'Water Supply(single) tn.tZ . f
IndustrialtCommerrial R�esalenfialWaterSupply(sltated) 1&GROVE -
nIrTieation FROM TO • NttIERIAL ID'+lPLACEREENTMBiHOD&AMOUNT
Non-Water Supply Well: O (2,Z IL G/I If c
MonitoringRecovery fr. ft.
Injection Well:
R. ft.quiferRecharge GrotmdwaterRemedietion S DIGRAVEIsPACK(lfapplksble)
Aquife Storage and Recovery DSalinity Hamer FRoat TO MATERIAL EMPLACEMENT METHOD
AgniferTest 0 Stemmata Drainage ft ft
Fare imental Technology DSnheitiPace Control It R.
Geothermal(Closed Loop) OTlacer ZO.DRILLING LOG(attach add tfonal sheets if ceeessary)
FROM TO D13�RWr10N Molar,harem%rdlJred(type,Itsata dm,de.).
3Geothennal(Hcati ap/Cooling Return) Dotter(explain under#21 Remarks) T O ESC P
/A 7 q ii
4.11Bate Well(s)Completed:6//7/23,Well IDIi 50, 20 S R. (12,-)Cil(
sa.Well Location: --b ---
GGr- ,
Fael7ity/OwaaNaa» - FaeilicyMB(fepplicible) R. it '�'
ISy8 /'BUJ il/(1i (. (iHa /G ft. ft. ' sit-jiv 2023 ilf
ft ft
Physical Address,City,aedzap 21.REMARSS Iil..,....,W.:,, i-)._`.:,a.c.,:+..,1 i)rta
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k S L}i�e'ai.h��i'JU
County ParcelldentificstionNo.(PIN) 1(
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sb.Latitude and longitude in degreeslnsinu i
testsecands or decimal degrees: _ .0,
Of fsld,ens►avlong is sufca nt) 22.Certification:
'6.4!2� .�o.39'CQt �
z
6.Is(are)the weU(s) Permanent or o empOravY Signe=ofCerti edWellContactor 3 r`•,,,
By signing this form.I hereby avg.that the weigh)sate Ovate)m,stmefed in accordance
with ISA NCAC 02C.0100 or ISA NCAC MC.0200 Well Construction Standards and that a }'
7.Is t a repair rm esivting well: ®Yes or No co a this+Tama hat&ao fa
lftlrrstsorgnrtr./IHaatlQ+ots`t>+rll�o+eiraU+onfnj°rmaN esplainisonaaarofthe PJ'j IRovl+kAtntleexrllmsaer:
repair under 1121 remark or on the back oftlrisf 23.Site diagram or additional well details: }
8-For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page la provide additional well site details or well i.x
only 1GW-lisnttded Indicate TOTA[.NIIMBFRofwells conshuctiondetails.Youmayaiwatmr$additionalpagesifnecessaty
eoHsnvction, Y
drilled:
SOBti91I'CA[,1NS11tUCUONS `}
2 2 5 (ft4 7Aa.For All Wells: Submit.this ftim within 30 days of
9.Total well depth below Fund surfaces y completion of well ''
For m+IdPfe mite llst all depths lfdgrenut(exa°'ple-3®200'and 2®f00) construction to the following: - 1
10.Scathe water level below fop of Ming:
(ft) Division of Water Resources,Information Procrning Unit, a=r:
I/tvtuer kvei is chive easing use+" 1617 Mail Service Center,Raleigh, r.,,
NC�7699-1617 .
IL Borehole diameter: --Cm-) 24b:ForFor Inl s: In addition to seeding the form tote nddre;s in 24a 4
9 above also submit one copy of this farm within 30 days of completion of well
12.Well eonslruetlon r b construction to the following
4
(ie,mg,.Minty,=bit, tITesh•etc-) Division of Water Resources, #nrces,Underground Injection Control Program, Y,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•
1)0 Method of fist: /101 in 24c-Tar Water Supply Ss trajection Wells: In addition to sending the form to q;�}
13e.Yield(gum) / l
�� 1 the addresses)above,also submit one copy of this farm within 30 days of
13b.Dislnfatlon type:_ At Amount: /GO 2- completion of well construction to the county health deportment of the county
where constructed. °ilk.
four OW-1 Worth C roliaaDepartoasntofEaaimnmenelQuaairy-Division ofWate Resources Revised2-22-2016 a�•�pi
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