GW1--05489_Well Construction - GW1_20230825

1
V6- "'l x-.yy a _____________:...:__-__I--...._________ it
Ii C- T t criON RECORD(GW-11 For Internal Use Only:
L Wen Contractor Information:
Cameron Bazin 14.WATER ZONES
Mom To DESCIUMION
Welt CaapaetarNene ,) ft. n.i t�:'y2 I
4518-A a. rt. H I
NC Well Contactor Cee<36n1ioallombcr IS.OUTER CASING(for multi-a red We11!)ORL)NSR(if ii..noble)
FROM TO DIAMETER THICKNESS MATERIAL
Aqua Drill,Inc. ft �o it In
DIAMETER
CompanyName fr IVNERCa•IG lotedl ,
warty
7 FitOM11 TO ASINGORTUB1 DIAMETER unelel IF.S r.
2.WOUConshactiaaP(smit ���G Z.- ft. IIIIIINIIM
EA/all applicable xeflcmrtraaion:emrfes am WC,auto:Sta[a Vadmm4 etc.) IIIIIIIINII
In.ft.
3.Well Use(check well nu}: 17.SCREEN y0 MA
TERIAL
Water Supply Wen: FROM TO DIAMETER SUITS
ii�; M___A`
jAgiicultoad DMunicipallPablic ft. g. 1n.
il
riGeothermal(Beating/Cooling Supply)/ Residential Water Supply(single) ft ft. In. �
DIndustrMI/Cammercial Residential Water Supply(shared) IL GROUT Eft. EMP AceMsxrrd�coD� •uNT
ILLK�on FROM TO MATERIAL
CitrAe
Nouon--W"ater Supply Wen:
QMonitoring ORecovery
Injection Well: ft. ft.
DAquifCTRseheuge C3GrtovadwaterReffiediatietn 19.SANDIGRAVEL PACK(if aPWi'eable) 1
e and R ;
DAgnifcr Storagecovery Es t Barrier FROM TO 1 MATERIAL EMILACEMrxTME[aOD
©IAquiferTest 10to mwaterDrainage R' r
QExpcei nlnl Technology QSnbsidemce Control ft ft. t
me
1
+
DR ;LINLOG(attach . nalstmemdaecesrar
0Gwthennal{CloedImp) Mincer
'DGeatbermal(Beating/CoolingRemm) riOthr(explainUndet#21Remarks) n ft y o ft. 44Y1, oFROM TO DICCRIF4ON( rI,hudem.rhak4lFe PF>��� )
4.DateWen(s)Completed: g2. Well Ma /y� s
�/)
Ix Well Location: it. I
R.Name FaciitylD(I(ifapplicab11(2171°2le)
/ �'
Phystealane:es,City,=drp �U`i �, 51 Zue�
1Q (:., • z1.REtNAltl{S i >fa;ic� •�,�';;,^ �a t.;i
County • ParcelIdeafifleationNo.(PiN) I R,�i QV•ii,.3vt
5b.Latitude and longitude in degreentminnter'Jaewnds or deamal degrees: -
(ifwcllSold,OHS latllang is sufficient) 22.Certification. 1
. 15 " N tem. 5 74n, W I l c//2
Tam nary Signature of Well Contractor I Dan
6.Is(ere)the waifs) Permanent or By signing this form I hereby cere that the:veti(s)tins(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.1s this'trefoil'to an existing well: Eilres or o a fhIr record dad to the wellawne r.
Iflhittsanwdr,Jllloatlbwwarvdleaatb aninformatlon oglaiatlrenauaaojthe PY I P+
rrpa'under 021 remark section oren the backeftlrlrfo 23.Site diagram or additional well details: .
S.For Geoprobs/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide addiNonel well site details or wdl
cmtshuction,only 1 GW=l is needed. Indicate TOTAL NUMBER of wells construction details.You away also attach additional pages ifnecesy�try. ,-
drilled: SUBMITIALJNSTRUCTIONS
9 Total wall depth below tend surface: c.,5 (R) 24a.For All Wells: Submit,iris form within 30 days of completion of well -
AormuWpleuclklist all depths Plifferent(esonple.Warm!2(a)100) comshuctlonto the following:
%a (ft) Division of Water Resourc Ytufarmation Processi
10.StaBc water level below top of mdng: . 8s, �Unit,
Venter level is drove eating.use+" 16171Ulall Service Crater Raleigh,NC 27699-1617
IL Borehole diametea: ') 24b.For Wells: la addition to sending the form to the addrzzss is 24a
ntr above,also submit one copy of this form within 30 days of completion of well
12.Well constradtlon method: 1 construction to the following: II
(Le.mum rotary,cable,dbatpusb,etc.)
Division of Water Resources,'Underground Injection Conird Program_
FORWATER SUPPLY WELLSONLY: I636Mail Service CeateevRmleip�t,NC 27699-1636
13a.Yield(gpm) •:l D�Ietltod of test: 71 d^ 24c.Foy-Water 6nnDIV 1¢�iretd.w., �e�. n addition tosentl'
: . s(as) above, also submit one copy of this form,with 30: to
lab.Disinfection e• Amoaak 1 a ration of well caaa c8on to the county health depatgttehtK �h IlaY5 of
where constructed. r
GW.1
m ,,, , North Coolies Department ofEuvinonmental Quality-Divisiona terRrxoein.,.