GW1--05018_Well Construction - GW1_20230807

11 tee' Y 44. . 1,1 ' ' e r ,-+'
-,,
.A uJ 4 f
•
a _ • i y^{` } y,-- .L 4.2 Ste$h •- S`l i
Print Form _ .. .
' _ :%% ELL CONSTRUCTION RECORD(OW—D For tame'Uec Only.
1.Well Contractor fntormanom ' I
' Cameron Bazin 14.WATER 7.GN S i
Weil CCI RCMN®c _[+B064 TO DESCRIPTION •
_ 4518-A g y a M IL I 4i/
<L ft
' NC Well Contractor CertiEsat'wntiumha IS.OUTER CASINO(for reoldeased wells OR LINEN(d•"liroble
Aqua Drill,inc. FROM I m 1 o>� 7mcxivrSS MATERIAL
Ctanp10EG
2.WdIlOe 16.INNER.CASING ORTUBIN'tG(k� Gdaed-Soots)
2.Weil Consirae onPaudtf: O I q 7 1 FROM TO nuaterE4R TmC RERs MAT L
List all applicable well dic npen ftr the.UIC,Comb:Daft Variance aa) C. ft. �
3.Well Use(ctlxkTreIlnse):
R. fc rn
I Water Supply Well: r7.SCREEN
'� FROM 7D D7AllrnTfalt SLOTSIZH THrt7rhT+SS MATERaAL t-y.
-cultural aMmnciprdlPublic It It I
Geothermal(Beating/CootiogSupply) Residential Water Supply(single) ft ft. I
Industrial/Commercial Residential
Watt Supply(shared) is.mows
imgatian FROM TO MATERIAL EMPLACEMENTMETEOR tS AMOUNT _
Nan-Water Supply Well: o M 71 tt t7 E
Monitoring Recovery FL it b
Injection well: R. rt. "::.
DAquifaRechnrge atimnndwaterRnnediartitm 19.SAND/GRAVEL Pant tifsPPue bte)
Aquifer Storage andRecavery LjSalinityBraier FtROM To MATERIAL 4 gAtpLA�TCaE[HOD
Test aSt Drainage
R. ft.
Impiret.Experimental QSubsidencaControl ft. R'
Geothermal(Cl Loop) �T4seer 2a.DRfI LR4c LOG t■tmeri addFaanal aheem u *Y)
satin Other(explaiaunder#Z1 Remarks) FROM TD D�cnrmarr tmLr t,,,ang,,mwNel erpaarmn��) _ .
t3eothetmal(H(Heating/Cooling J (7 m a lj(llrn b�^ e
(i7S/2l wenIDO' R. r !t I\ .A_ $'P, 't,',r--‘• ..
4.Date Well(s)Completed: f �p `S Ov`` — '--r,.,,;b r il.,^'1.
ft. n
52.Well Dilation: — .,.
�. It
(f-re g -'Z'GIIAI►ta�5iid sc I l(J7� �,
Fat yIDS(ifapplieable) ft - S
ft. lit
114t:ii , )
physical Address,Cay,and rip
4'^rt7 2L REMARKS
Ccemty !V PeselldainhcaaattNo.(PIN) :'ft
5b.Latitrde and longitude in degreedrolante/seconds or decimal degrees: 22.Certification:(dwell f gild,we�S is suf;xices)
6Z4 4 2 ;t
3G ����� �o Z w
Sigma=ofCetifiedWellContRdor Date
i.Ware)the ereD(s} F'ermanmt or 1 1 mrpora►Y By signIeg this farm.I hereby cent&that the wrB(r)war(ware)coratntCef In accordance
to existing well: ayes or o with 1SA NCAC ICC.0100 or 1SA NCAC cue.0200 Weil Constractio t Standards and that a
7.is this a repairarmattwr oplaln thetwaa a ojthe copy ofthts rerDrd has beat provided to the well ..
Ijtlrit Lra rrpah:lt!!audtrrovm treA ootttoeu8ma mj
,cads undo Oil rnsmisse:don or on do boot of Mai 23.Site diagram or additional well detail; ,
Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
E.For Oeop cob'be/DPT or Closed-Loop de nets consnoedon details.You may also attach additional pages ifntxasasy.
caashnetiaa,only1 G is needed.Indicate TOTAL NUMBER ofwells
drtl1ed: SOBM1'1TAL INSTRUCTIONS
Z.g (ft.) far
) 24a.For Ali Wells: Submit this m within 30 days of completion of well
9 Total well depth behave lead aTDitte�
Far ardapie netts llstaildepda(ferffaatsic zner-3@200.1320226a007 construction to the following:
ill Stale water level `j`' (ft) Division of Water Resources,Information Processing Unit,
limner level� casing,we+« 1617 Mal Service Cceter,Raleigh,NC 27695-1617
abase 6
11.Borehole : } 24b.For submit
Wells: In thiattrition to sending the foam to the address is 24a
I above,also submit one copy of this form within 30 days of completion of well 4
12.Well eoratratdion method: construction to the following
i.e.anger mtary,cable,daatPobt a..) Division of Water Bourses,Untie
ONLY: 1636 Mail Service Center Raleigh,)Nt7 6991636 Program,
FOR'WATER8UP1"LY WELLS �J
1(/ MethOd of tit: ►ll � �For Water Sanely&Joiection Wells: In addition to sending the form to
13a.Yield(Epm) the wldims(er)above,also submit tine copy of this fmm within 30 days of
---^ Atnoatt lfe'7� axlmpledon of well constraetioo m the county healdr dapattrnert of We rwmty
13b.Ohinfeci typE: whew constructed.
Not h care=Department of Environmental Quality-Divishm of Water Resancec
Fob GW-1 Revised 2-22-2016