GW1--04364_Well Construction - GW1_20230707

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.4 WELL CONSTRFelliON RECORD itGW4.) r latental he Oy: :: :1 " '
!
1 1.1Rfoll Contractor Information:
-_
Cameron Bazin
14.WATER 2014IES . .
Well Connecta:Warne FROM TO DCOPUOI " t
4518-A "
cie.,5 ft' , '' ft' -41e2^
NC'Well CcuaramorCedificationNmnber .
,
IS.ODIER CASINO(fermalti-ressed wells)ORLINETt 6 •• _ )•' :,_ -
Aqua Drill,hie.
FROM TO DIAMETER i THICKNESS , MA
' ComposyName 0 ft. 75 fr. : ,.‘ la ' ' rkc-
•
2,Well Consiaftetion Permit& 31/..72 4. 16.INNER CASING OR 710MTIG gstothermal dosed•fortn) _
FRoist' TO DIADIECER THICKNESS " MATERIAL ,..... 7
.___ List an stplteable tea aatettetton prate(La.WC Caw*:Stale Variahoe etc) ft. . * ft ID.
.‘...
3.Well Use(elteekwell use): ft. ft. '" 03-
. ..'-
Water Sup*Well: 17.SCREW 1,
FROM To T
- ' DIAMETER ,MAWS= HICKN MATER/AL ESS
DAgricultural OmtmicipallPablic ft .ft le.
, -Geothermal(Mating/Cooling Supply) 31tesidential Water Supply ft. it
(single) i - in.' ; •-.' - .,
IndustriallCommen )
tial friltesidentiU1 Water Supply(shared) Ia.GRour ,
Inigation.
FROM- TO • MATERTAL EMPLACEMENT METHOD&AMOUNT
Nort-Water&apply Well:
e) ft' 9-g. ft, e.:./rikr
Monitoring CliRecovery ft ' ft:
Injection Well:
ft
• Tiller Recharge OGroundwaberRemediation
19:SAPSINGRAVRI.PACK ftermenbt.1 -
. 1%clam Storage stld Recovery E3Salinity Barrier FREW TO ALATEIVAI. PHIRLACEMENTMEIBOD
11!Aquifei Test EDStismsvater Drainage it ft.
t :
ill • .....,...,": Technology Osnbsidence Control ft. it. _
ii Geothermal(Closed Loop) :]Tracer 20.DRILLING 1.0‘C(ettieb additional Sheets If necessary) - •
, .
1:1 __•Geothenna oleatinwcomitm Remo rlother(=plain wider gm Remiuks) FROM. To, nastsunton„ _ ream taxcee3;:enneektmeareue rure.ere) .,: . ,
0 ft. 6/S i!' 4zisa. , ,,,
..•'i 4.Date Well(s)Completed: 7.g7'2 3 WelliODB ft• ,,45 ft' R:pijk
t. ft. ft.-1 Sa.Well IfAcation: • . .
i 1 64-(1/15 A/0*Zr— ft. ft.
• .
'1 froditylOwnerNante Facility IDS(it'appliesbie) ft. it. .r „
-,,',77_i'-Fr_fil fc.n
35./ ft ft.
f l D. ft
Physical Addless,City.and Tip I! I p 7 211?1
Ailfhtmy si.REMARKS
,i •
County Ruud kifsnificationNo.(PIN) 111,-;,- -%f.ir"71 7)r!"•t.7!Fyla..?..1 liri _
5b /7:30G.Latitude and longitude In degreesbniontesiseconds or decimal degrees: DV,f0 i (if well field,4mc loitung is sufficient) 2,?-Certiffeallon:
! 3452619? N So- 73518
syr2
Signature ofCertified Well Contractor 6.Is(are)the well(seramment or E3Temporary
I;
. au
7
' ' to an existing welk DYcs or No By signing thtt farm.I hereby etrtZ that the=gm t (wars)atitttneeted kJ cteertniance with 1.54 NCAC 02C.0102 or MA RICAC°mow Weli Construction Steam&anti that a
.Is this a repofitiri aid awe well
. worm°• wid mod,tha wiw„phe COpy oft*record Inis Feenplovide to dieted 1 owner.jlepaIrigt:der 12,1 mark t section arca the back of thief
You Site diagram er additional wen detsult! .
0.For Ge be!DPT or Chned-Loop GeothermalWells baying the same maY.use the backof page to provxdF.addiattonal wellil site details or well
cti G on,only 1 W-1 is nets:led.kuhcate TOTAL NUMBER°fusels onyouumyoko
drilled;
60 5• SUBMITIM.INSTRUCOONS
9.Total well depth below lan.dl surface: re_30260.and201003
00 2411.For 411 Wellm Sem*this item within 30 days of completion of well
For mahlpte walls Ho all deptlit ifiriffleett(romp
consttnethm to the following:
10-Shift water level below te2puf casing: /00 (ft)
Division of Water Retources,Information Processing Unit,
fluster level is abuse cask%ere + 1617 Mall Service Center,/Raleigh,NC 2769407
11 Borehole diameter ti CIO 24b.For Infection Wells: In addition to sending the toms to the address in 24a
. -
C01-09/' above,also submit one copy of this Dam within 30 days of completion of well
12.Well construction od
construction to the following
•
meth -_
os,..mgr .....ro..._,,cable,diftstPtlisk dea
• DitirSion of Water Resources,Underground Injection Control Prognnn,
17---VV 166 Whila Seicery daidzr,Raleigb,NC 27699-1636
-- -EaTORyieAl:tgrrn:nt:____PL—Y WELla ONLYpigethort of haste /2'414?-4— 24e-EEL Supply&Inlection WaslIn In addition to sending the farm to
13n.
wthletereaddress(constnesmed.)above,also submit one copy of this form within 30 days of
/49 completion of well construction to Me county health departmem of the count
1
worth cthotEaa Ogroutment of Envininntentst Quality-Divisin'n of water Resources
Revised 2-22-2016
Form GW-I