GW1--04668_Well Construction - GW1_20230721

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1- �ContractorWar/nation: For al U�only:
Print Form
Cameron Bazin •
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�. DIMIEIMI THICKNESS MATERIAL
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( allC Supply(single) ft. ' ft to
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18.GROUT •
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.' - Storage and Recovery DSalinity Barrier 19.SAND/GRAVEL PACK atappfied,le)
It "ferTest rteoM " To MATERIAL I EMPLACEMENT rmIBoD
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illccbnology psubsideace Control ft.*Geothermal(Closed Loop)- °T
racer 20.DaYLI.rNG LOG(attachaddF/foasleheets Lfnmssarr)
*Geothermal :eaten;Cooling Return I Other „.'amide,#2/Remarks FROM TrO DPSCRiPlion tonot wntasc wwcef tree. na.ere.)
4.Dote Wel(s) : c7(V1 ' Wel1 D# ( f. 7 S R rif(o c
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Physical Address,City.andZtp
i' REMARKS _
�1t��� 21 REMAR I?)+nG rF.'va;:�l(�'•:-!':�yiW:T I h;i{
County Pan lIdeatifiataarNo.(PIN) t>�°a a',�t+
. 5b-Latitude and longitude in degrees/naiunteNseconds or decimal degrees:
(Wadi field,cos tetRong is sufficient)
22 Certification;
. fi.(1) So Iv , .5 3a0 o w
_ 6-7s(arre)the if�1(s)WPermanent or °Temporary signature afCehtifiea Well Contractor
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,�{ � By signing this form.I hereby car*that the wa(+)war(%R7e) is accordance `.
7.$Ws i r to air existing well: I�Yes or Q 1Vo with ISA NCAC 02C.0100 arISANCeiCO2C.0200 Well Corson Lion Standards and that a
, trchfrig---et.• air•,filloutbarn wellcarubretionfnjmmatlaaGndaplatatlre+ranarofthe �DYalt rh hasbrehgrav►dedmthexalta h
nipairdreier VI nerrharksseeton or oa the back oflhlsfonn. 23.Site diagram or additional well details:
•L ai's;Geo/probe/W er Closed-Loop Geothermal Wells having the same you may use the hack of this pogo to provide additional well site details or well
construction,only I GW-I is needed.Indicate TOTAL NUMBER of wells a on des.Yon may also attach additional pages ifnecasaly-
dr171ex1: St BN>f17[ALJNSPRI1t TX4NS
Told depth'below htlyd semfsee: a 3 mrd2{�lnory (ft.) ma.)For All,Wells: Submit this form within 30 days of completion of well
taufdpic >Yffa( i connection to the following:
1 10.I‘dtr,w level helew top of easinge ' - "1 to (ft-) Aivlsian of Water Resources,Information Processing Unit,
Ironer level Fa ohm essfa "r" 1617 Mail Service Center,Raleigh,NC 27699-1617
71.Borehole diameter: h` - (iti,) 24b.For Infection Wells: In addition to sending' the forme to the address in 24a
Well method: (1) above,also submit one,copy of this form within 30 days of completion of' well
(i e.angel rotary,cable,directpulb;�).-
coostlrrc ion to the following:
Division of Water Resources,Underground Injection'Control Program
FOR WATER SUPPLY-.'15 ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 '
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13a.Yield(gpin) � ?l Method of test: I 1 29e.For Water Supply&!election Walls: In addition to smiling the form to
l J fi 1L I the address(es) above, also submit roe copy of thin form within 30 days of
13b.Disinfection type: It Amount: '�fy7 . completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina DCpartanatof Environmental Quality-Division of Water Resources Revised 2-22-2016