GW1--07797_Well Construction - GW1_20231201

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C1 TRUGTIO RF(-(IRS W 1) 'tint Form
Fat-Internal Uso Only: _
1.Well Contractor lnfbrtnattoo:
Cameron Bazin
WO cone ---------- -is wATaR .OtlfB --
4518-A raaM ro °sacwrtan
NCcacti Cenh.ctor f�tti0atien Number _1435 ft.
Aqua Drill,Inc. r.'...--" LC o c c nor mtttt4esed well Kin LINER(II Droste)
r"" Il TI�t.7alua MATERIAL
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CM:my Q R. 00 R.
2.Well Construction Permit#: 'le 2 If.INNER CARING OR TUBING Pia:-
trod elpsed-loop)
Lire all oPPltaable Nett awns mcdon parents R.e.fifC Quota shoe.Pndetes.eta) Fil":" rt. R. DIAMpi:a Hr. KTra THBas MATERIAL
3.Well Use(cheek well use): R. -
—tti Ili.
Water Supply Well: 17.KARIM - —
cnitrttal ©MtmieipallPublic FROM TO R. DIAMEf6a. !7_OTSEB TIIILTrIt!!e MATERIAL
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) —
Industrial/Commercial 11 R. to
Residential Water Supply(shared) IS.GROUT
&rim Edam FROM
To
Non-Water Supply Well: .MATERIAL EINLACEMERT METEOR&AMMO.
Monitoring °Recovery R. S R G i^DJ
Potion Well: R. ft.
Aquifer Recharge
©GroundwaterRemediation ft. R.
Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK OS apRneab4Z-
FROM TO MATERIAL_ EMPLACEMERT METHOD
Aquifer Test DStonnwaterDrainage ft. rt.
Experimental Technology °Subsidence Control R. R
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(IMsch atleitioad Itttalata a asennry/
Geothermal Qlcating/Co cling Return) nOther(explain under#21 Remarks) FRpsl TO DMICRIITa�ly(mist,Imam%srWiaek type,E da dm.m.)
It i
4.Date Wells)Completed: f o/23J2� wen m# c n' 2-C - A."(
_ �,3o ZZS �a<f`
5a.Well Location: et. R
0A k(,,...t l4 o' e' ft. a
Fa Owner flame Facility ID11(if applicable) IL It.
?i [$ A16d;( to 'I}t, C tor&i3O,7- IL a. I j i 1 iJd 3
Physical Address,City,and R. rt.
—
air-a(...,6,-,._ 21.REMAnlos _
County Parcel Identification No.(PIN) —
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
—
(if welt field,one ladlos g is su ideat) 22.Certification:
r) 5• 3,0334 N 811 163v( W
7i-N._ — //2.3/r7
6.Is(are)the we l(s) Permaueet or °Temporary Sig tattim arc atiiod Well Contractor pate
By signing this form,1 hereby certifp tilt the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 1OYes er.0No with I SA NCAC OIC.0100 or 1 SA NCA('(MC.0100 Well Construction Standard:and that a
silos 1s a repair,fill out bw n well oaastraot(arr in formation alplala the nature of the SPY ethic record has been provided to the'evil owner.
repair under#21 tetrads section croft the Mahar this form
23,Site diagram or additional well dotatls:
8.For Geoprobe/DPT or Closed•Leep Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:�-- - _-_.-_ SUBMITTAL INSTRUCTIONS
22 S
9.Total well depth below land surface: (R•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells Nst all depths(fd(Berent(example-3@2O0'and 2®l00) construction to the following:
10.Static water level below top of wing: SQ (ft.) Division of Water Resources,Information Processing Unit,
if meter level its above cusiag.toe"+" 1617 Mail Service Caster,Raleigh,NC 27699-1617
11.Borehole diameter: e. ( ) 24b.For inflection Wells: In addition to sending the form to the address in 24a
t�� above,also submit one copy of this form within 30 days of completion of well
12.Wef1 construrdaa method: u p construction to the following:
(I.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
1130.Yield(S1len) �0 Method �'��I 24e.For Water Supply&Inierda Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.DJrinfeetion type: _, 't f� Mount '�` whom� Hof well construction to the county health department of the county
Form GW-I
North Carolina Department of Environmental Quality-Division of Water Resoutos Revised 2-22-2016