GW1--05592_Well Construction - GW1_20230825

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CTIONRECORiDCOW-11 For Internal Use Only. j 1 4i;'
1.Well Contractor Information: ; "'
Cameron Bazin U.WATER ZONES 1
Well Commeraexame FROM 'To DEBCRIPOON q �„r•-ik
4518-A (,8t; it. R. ,.,
R. R. t i4s";,Y
NC WellCatrttseemCatiEatianNumbs 15.OUTER CASING LIEmatdcasedwellstORLRORtareppllable "'.?:
Aqua Drill,Inc. FROM To DIAMETER THICKNESS MATERIAL — ys,- .
0 R. 53 6 IE. Fie ' v,--s1
CompesyNome a
l (/ 1GIOVNER CASING ORTUMNG eeatlarmolelated-bop)_
2.Well Construction Permit#I f `71r q C FROM TO DIMMER TRIMNESS MATERIM. ".f``'
Liu all applicable wellcmatruction permits(le.Ara Cow*State.Irarlmeee.eta) ft. ft. la. « i
3.Well Use(cheek well use): tt. it. to. ;si, ;
Water Supply Well: 17.SCREEN FROM' TO DIAMETER SLUE SIZE THICKNESS MATERIAL •ti,X
•,• ' turn! OMonicipaUPublic {t, 're. to. >" ^.
I Geothermal(Heating/CoolingSupply) idealist Water Supply(single) R. io .44.470
°+"
iii industrial/Commercial ' 1'
RcsidemtielVJataSupply(sltmed) �+•
imgatioa 1 GROUT TO . MATERIAL EmmAcEmmermemory&AMO re ,
Non Water Supply Well: 0 R. 27 ft- G i.r,e 5- t
it Imitating Recovery R. Is I '•
Injection Well: It.
a •'1"Recharge DGronndwaterRemediation i
' ' >Storage and 19.SAND/GRAVELPACKfd'applieable) -
01: Recovery DISallnityBarrier FROM- TO MATERIAL EMPLACEMENT
111 '. -Test DStmmwaterDrainage R. ft. .
R ••crimeatalTechnology DSuFvdrwrrCannot R It
III Geothermal(Closed-Leap) (Truax 220 DRILLINOM G G tlachdd
sheets Newton* ,
•Geothermal(HeatmgCoolingRmrm) ElOther(expleinunder#21Remaiks) O ft. y$ A R, a0. DESCRIPTION e anrr*ksoe Min en MO
4.DateWell(s)Completed: 3/1-7/t3 Well ID# 95 R' ZZ S A ROCAI
5a.Well Location: it r6 s— ®per ,`
/r__G9 ./IL S tit R li'"4 6°0. a 09d li e. .,
FacRII3t(�IOwcer Y Facility WeOtapplirable)
1/ J&-v Q c C . . (�'raSSy,Gc it R. AUG ZOZ3
Physical Address,City,and Zip A ft
2LREMARKS t t Cfl ref:c i@rkrr?i l;nai t
/���nCt'30ev
Cmmh • Docelldemirica ianNo-(Frl�
5b.Latitude and longitude In degree in louteslseconds or decimal degrees:
Of welt field,one lnt/tong is suffc®t) 22.Certification: ,+,'3
`9 6, S 53cPr N $1. 3$��g w /� 0//772 3 F#
Signature ofllettlfii wellCoohactor Dale t ,,
6.Ts(are)the w Afl(r% ermannUt or EiTemPftrftrY -
By signing this jam.I hereby are that the ixU(s)n (Ave)wrsrractcd In ac urdance <;'t"i.„I
7 this a reps to an e7oisfiag Well: QYes or No with ISA NCAC 02C.0100 or 15A NCAC 02CA200 Well Construction Standards and that a '
oollomnyt yer(l cvmttraction Wamarla aplain me nature of the copy opts record has been provided to the wellowner.
fir*is arepairuader021 renter&se section thebaakojUrrssfarm 23.Site diagram or additional well details: "(
Yon may use the back of this page to provide additional well site details or well °I.'.
S.ForGeo.onlyAPTorQoseded.ThCeotha Wells having the name construction details.You may also attach atbEtionat pages ifnecessaxy.
coastrrtction,only 1 GW 1 isneeded.IndicasteT'OIALNIJIv1BPAofwells
drilled: 5 SUBMITTAL 1NSTRuCTIONS
9.Total well depth heiaw load suriacre Z 2 (fk) 24a.phi All Welk: Submit this form within 30 days of completion of well a,t
For multipleivel&lin all depths fftEferetrt(exampfe-3(a)200'and 2®100) constructiontolhefpllpyying� �•
i67 (it) Division of Water Resources,Information Processing Utah, ;
30.Static water level below eV of casing:
limier level is aboveaarhoIlse+" 1617 Mail Service Center,Raleigh, 27699-1617
,t
1L Borehole diameter: b7 gm) 24b Far Injection WeftTn addition to sending the form to the address in 24a
e�� above,also submit ens copy of this form within 30 days of completion of well
12.Weil construction method: / construction to the follotving
(i e.auger,rotary,cable,darctpasb.etc.) I'
Division of Water '
Resonrres,Underground Injection Control?regret% F
1636 Mail Service Center 12rd
FOR WATER SUPPLY WELLS ONLY:
� eig)yPiC 27b99-1636 �};;.
Method of 'JU�Irft Z4G For Water Suimiy&Inlectlon Wells. i
13a.Yield(gpm) the address(es)above,also submit one to 1;t addition to send'mg the form to
1{�1� Amount: (�02 completion of well construction to the canny'of'this fool within 30 days of
131LDl9lofecdontype: where constructed. tyl health depattntent of Hie cotmty
Form OW 1 NatthCamliaaDeparcoeptofH°vit°ameadQ�lity-Diva W
Division of
Retained 2-22-2016