GW1--06272_Well Construction - GW1_20230926

fi Q
I
Print Form
'WELLCONSTIWCTION RECORD( 1) For Internal Usc Daly:
I.Well Contractor Infarrnatlaa; 1 t
Cameron Bazin 3
I ITCHComecmrNeme i4.WA xzoRr+s DESCRIPTION
shoat k
1
i: 4518-A GSS1 fa t
l
25( . `
•{ NOWellContmctorOntibalionNcmtber R. re
I, " Aqua Drill,Inc. 15.Onr®e CASING(for matti•asedwas OR LINER RN WA/
Ili
FROM TO DfMtSfEn TraaavEgs MATEnuL }
2.Well Canstraceionpenrdtth I' S 171 EROMriEReesnvcoRTri9lldG(eeothe dascdaoan)
i
Ltstall bkxdimesaarltaa mou TO DIAMETER Ticaftems MATERL�L
Fe+ettts(Z4 WC Comm Side,Padmcoi ale) ft. tL to.
I - 3.Well Use(chechweu & tL ta.
use): I
} t• Water SOPp(y Well: 17.SCREEN
-colnnal FAOlIi TO DIAMETERis SLOTsJ7B TRIOCNPSS MATERIAL
f QeothtYmatel(Heating' I Supply)
/Coo' O •MunlcrpaUPublic fa f tt' Water Supply(single) tr. I (o,
lit Indusbia'YCommaricl Residential Water S
ki lion u pJy(� ) 18 GROUT
Non-Warm Supply Well:
FROM TO ' MATERIAL newr.AC�a METHOD stAM R= i
Monitoring 0 IL ?5 m (;Lsl t
Injection Well:
Recovery R I
t©��Gt�onndwaterRemedietion EL R` I
StomgeandRecavery E JSa„m1yBarrier W.FROM TO
edtoAn
EMPLACEMENTME[HOD
Test Drainage
¢¢
Experimental Technology a5nbsideaceCo ft, it i .{ `
• Ceothonnal(Closed Loop) °Tracer 20.DRILUNG LOG(attachadii'dfooal tines ifnxouslo)
, Geothermal(l tinp/CoolingRanaa) fOtha(cnplainunderRIRemarks) saner To DrscxtttroN(mmnt,o�s+mnrmekeaa n.taeee)
DESCRIPTION
4 I
4.Date Mika)completed: 'q/5/217 wpmR: 2 LS fr. 1 nn y
Ode( 1
5a Well Location: a. it .
CI --:'T 1
•
Facility ft. n 0 ,°l i�e� i��.+
15 1 k Ar6,94 rJ- 1-61tAre I SpiSn IL ft. O
PhysialAddoss,GSty,mdyp ft. tG JCP 1 .e 2Z3
I1.
-,,_ _m._.?�Una-1A et.REMARKS : , ,
1 G;1 ;fj r.in0 n: County PaeeelldeoTiHeaoallo.(PIIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
'. often field,OW le hags sus eiem) 22.Certification: }
a
• . Data
6,Is(are)the welr(s) ermanent or °Temporary 25
•
slyroeeeco 6ai Wall Contractors(
Bysigning this faint I hereby we that the nell(s)ma(were)constructed in accordance
7.Is this a repair to an existing well: iE f Yes or o with ISANCAC 62C.0100 or 1SANCAC 02C.0200 M U Cwo;truc0oa Standards and that a
rote fro rcpatr,/it(oatiaonn weltconstruction iafonaatio containthe aaaaeofthe coyof this recordbasbeenpiovidedtoMenailamen
repatranderd21 murk scanner on the bacicofthisfomi.
23.Site diagram or additional well details
S.For Geoprobr/DPT or Closed Loop Geothermal Wens tmving the same You may use rho back of this page to provide additional well site details or well
construction,only 1 OW-I is needed.helical*TOTAL NUMBER of wells construction details.You may also attach additional pages ifnecessaly,drilled: SI1BAfITTAI,INBTRIIC+'rnroa • i
9 Tots!well depth belowland surface: Z2 3 (ft) 24a. Hbr All Wells:Farmotvpkwellsarraildepthsfdrremit(eromple-B@2Oo'and4 )1003
a Submit this fomn within 30 days of completion
/' nsttuclion to the following: 1 p etion of Well
IQ Brattcwaterkve36elowtopofesaiag. 7 ((t) DlvlalouofWaterRegonre
Ifubterlevel ts above crubrg,the+" 1617 Mall Service Caster R®Irmation Processing Unit, .
1L Borehole diameter: (In) + gt4 NC 276991617
246 Far Inn n gIe11_; run to
12 Weti construction method: n'?ray shove.also submit
theono
nowi It of this f�within 30 daYs of completionsof well
er
r saga,EDm y,cable,darrtpaah,etc.) to
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground
1636 Man Service Center, leig Injection Control Pro
13a.Yield(Spat) 2 5 Method of test: S/c r— 24c.Fo wale Raleigh, .27699-1636 °'
the addresses)above, su---2 o e 00 I I. addition to sending the faun to
13lL Disinfection type: !� l� Amount i�� �i completion of well co �pY of this farm within30 days of where constructed. construction to the cfm*Y'health
tetlt of the county
Faun GW t North Cemlina Department of Environmental Quality-Division°Meter
Revised 2-22-2016
rssa . w rxF E �yait i'Pi.a 1 } "�� 4M rf ri