GW1--04171_Well Construction - GW1_20230706

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1.Well Contractor Informatiom 7
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Cameron Bazin -........,,..._
14.WATURZONES
Well CoaltactoTNamo FROM TO" :DESCRIPTION -
4518-A C it•
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NCWell ConuarrorGutiftratiAnNumber ft.. ... It.
Aqua Drill,Inc. .1.s.ommeCASING(formal-cased we* ORLINKRilf 111:010 : ,,• ,
1.FROM- * TO •. ,DIAMETER` .THICKNESS, .• MATERKH.
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C.mopanyName
2.Well Construction Permit ft: 002)3 b. 16.1NNERCAKING OR TilliiNG @alb:caul elmed40010 - • : • - = ..• 'r-
FROM---' 'To• . - M DUKES= THICKNESS .,.• ATISRLU.
, . .
List alIapplieable null ounstructioagennift(1.d.UIC.C=4:StakVanaltce.. .- elq ft.. .
- . . ..3.Well Use(cheehtvell use): ft. ft - in. - ' . • - •
. .. - .
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Water Supply Walk 17.SCREEN : .• . . . ,
. ---...„
°Agricultural Ohlutticipal/Pliblic FROM,_ to. _ ..; DIAMETER.. SLOTSME- THICKNESS• _MATERIAL- .
EL ft.
DGeuthermal(Heating/Cooling Supply) A'.•esidential Water SupplY(single) .. _
ft. ft. in. • , .
OlndustrialiCommemial r 111Residential Water Supply(shared) •
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.ilrrigation
• .su001- - .To • omoutrAr. imputcsonumBrnon&Amouwr Nen-Water Supply Well: _
-0 _ft" ?•- . ft* -.(A.IIK . -
ft. . ' '• •Monitoring °Recovery. •
' fr.1 -
Injection Well: . ,,.. .. . - •. . . ..., • - -
• R. t.
'a/Aquifer Recharge E3CuramtheaterRetnediatioit • - ., , . _.. .
. ...
E3Aquifer StMagesodRecovery EpSalialty Barrier 19.SANDNIRA VELPACKlitamilleable) '.. - .
FROM.. •- -m
MATERIAL : . 251ELACEMENT METHOD
OMNI*Test OStommaterThaiesge it•
°ExperimentalTeciMology DSnlsidenee CAtarol ft.- fc: ' . . •
OGeotherinal(Closed-Loop) Drina- .20.DRILLING LOG Canna. addition:diktats Harasser* ,'..---
Geothermal(Realitig1Cooling Retam) .136ther(esplainunder al Retaiks) .T.FROM - ':-TO- .- D-7ca-ff7"-frabr'iu-rkz""°2.1•"mk"'e'er"'17."3` '
R. •Z tl=- 444-
4.liateWell(s)Completed: 6/6/21 weamn - 2, ft. ft. .1P-oak , C.3 7,,i,. ::.1----•Cki "771.....'.. . .
•ft.
Sa.WellLomeon: . •
64#4 PG-nkel ft: fr. . , lip 0 6 z.u3 , •
ParDitylOwnerName Facility IDS Reparable) ft. tt.
. - -,..._ 1;r.,-....5., .
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S u((1/ -6-6tbert) 0, f i in fr AtlirA/ ft. ft. .
rk,.-10,1A,",_)‘::
Physical Addriss.atk=drip ft . ft. ,
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'=REMARKS. . . . ' . • -
County Pateel IdentiticationNo.(PIN)
513.Latitude and longitude in ilegretshninutestseetnids maximal degrees: • -
(if well field.one laglong is sin:Eckel) 22.Certification:
"- t. 1/St . N AO,5070 er w --- 2----- - ,
Signs=of Ccnified WeR Canon* (/,
6.Is(are)the vielks)526'erznanent or °Temporary
BY SWflif glif fOnit I!Web,fidr*that the well(t)tali(mai)auto/wed to accordance
with 154 NCAC OW.0100 or 15A NCAC.0.3C.112011 Well Coutnrethia Staid an*anti that a
7.eat dais a mimina m*21:flu autto aLownexiVingweil comarcigianweng ElfonnYes otiocrifinstplain dte Rau*elk, copy ofthirseetud has beat. pnvIded to thews!1 owner- .
ifre;ah.under2I resnada seethes eras the back clads fcern.
23.Site diagram or addition:dwell details: -
You ntay Me the hark of diis page toll-UMW additional washy detaUs or Well
K.For Geoprobe/DPT or aosed-Loop Geothermal Welli having the saine
constitution detaib.Yon niay also attachadfofondpages womanly,
Mien,only 1 GW-1 is needed.Indicate TGfAL NUMBER of welts
• dolled: - . .
S t 5 PutearsikunTRucrioN4
(ft.) 24a.For All Welk: Submit this'Mem within 30 days of completion of well
9.Total well depth below land surface:_
For e wells listalIdepths Vertffitent(erample-3,a280'and 2@l00) constinctionto the following:
- (ft-) Division of Water Resourees,Information Processing Unit,10.Stade water level below top of casing: -
• 1617 NM Service Center,Raleigh,NC 21699-1617 rwater level&above casing.use"+"• A
(In.) 24b.NO_Chtleetion Welli: In addition to sending the form to the address in 24a
LI.Borehole diameter:-...- ----
above,!Igo subrait one copy-Of-this Rim withim 30 days of completion of Well
(AP TM,.Wel ruction method: .• to the followin5
12l const
lin amen ToMor,cable,cractI rah,etc.)
Division of Water Rtsouries,Underground Injection Control PrOgram,
FOR WATER SUPPLY WELLS OPMY: 1636134211 Service CeoteriRoltigit,Nc 276904630
ic,t,r
Method of test: ./- • 24c.For Water Sum&delialection Wells: In addition,to sending the form to
13a.Yield(gpm) '20 the add (as)above,also submit one copy of this Vim within 30 days of
WI- Amoun
2t i60 .- completion of well cousins:dor to the county health department of the County
i3b.Disinfection type: whem constructed. !
• Nail,cmgca ovarontot ofEuvireemeatol Quality' -Division of wawa:mums Revised2-22-zois
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Form GW-1
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