GW1--04120_Well Construction - GW1_20230623

WELL CONNTRIIC�®N RECORD( a11 For Infernal U.sOnly: •---__
1-Well Contractor information:
Cameron Bazlla 14.WATER 7dDPlfiq
Well Cote actorName Pitc--111--r---------onimS tr _
r
4518-A 385 R it. S 41.
ft. rt. I
NCWel1 Contractor CertifieationWttmber
IS.OREMCASINO for multicasedc�Ilr,p GRL (ifa 11able)
Aqua Dull,Inc. FROM I TO MAME= l THICKNESS MATt ttFaE
Cotepanyliame IL ft. fin_
( , 16.INNER CASINO oR'i"t1Fm+io(eeatlrertaal clase6400
2.Well Construction Pertmit& 0:12Ad.5 I-a°a '©1 Sd`C most TO DIAtYlETCR _TRIMNESS MATERIAL
List all applicable cell construction p.irub Lc.(MCCowity,Stag Pariancc etc) f6 fL EEL -
3.Well Use(check well use): ft. fiL in.
Water Supply Well: 17 SCREE-N
1111 ''1�Ct1111Iral FROM TO DIAMETER SltyrSIZE TRIMNESS MATERIAL
�' Mnnicipai(PabliC iZ ft. i0.
'.Gethezatal(Reatingraooling Supply) AResidential Water Supply(single) ft. it. in. -
i Ii1dusiYlal/C®nimexcial E3Residential Water Supply( )
1e.GROUr - •
it Ini.:Eon FROM TO ' MATERIAL ERIELACCMENrMETHODa.AMODUNC
Non-Water Supply Well: f• it:
*Monitoring 13Recovcry rt. cc
Injection Well:
at quiferRech +Recharge DIGroundaraterRemediation
' 'for Storage and 19.3AAWIGftAVI PACKEapplcable) -
lac Revery DiSalinity Barrier FROM TO MATERIAL IERFLACIMENT METHOD
Ter Tea DStonnraterDaaioage ft. ft.
all ExpaimentniTechnology Snnridmirt'Control ft. !t.
111 Geothermal(Close[Loop) OTracer 20.DRILL/NG LOG(catch a*Mondl stints ifnamsory)
ili Geothermal(Fleating(CoalingReturn) Other(explain under#21Remarks) -FROM TO Dsa�CR>prcovtmu,:nm .murcasRscar, nuze.�e1
(g S fir '-jZ, it• P,Qri .
4.Date Well(s)Completed: 003 Well Mg ft. ft.
Sn Well Los:atom ft. f. .
C l',n\ Sbak,' r✓ ft. It. b`4 ..:" . -�,c tf g, ,:��
PacilitylOwzwrNaina Facility lnrl(if applicable) ft. R. .. ,,:
!Ili -l'iM6etl,t-oovl h-( . �(rA'4--(� JlilN 4 2023 -
Physical Address,City,aadZip ft. ft.
141 '----,',,^ -7'5
7Mtf(()/ 2LR$M/lR1/CS i� _ D`ya+t.au'3+;, •: I...-VA
County Parcel Identification (PIN) (J�l'(� t./�}f�
Sb.Latitude and longitude in degreeslminatesiseconds or decimal degrees: t+
(ifwel)field,ens la nose is�+,Cgr.-at) 22.Certaication:
34.3A/o , N 8t0.8y , w
6.is(are)the weals i1e'arrnanent or JTesaporary Sil antutcofCertifiaf WellConnaetar �Y
By signing this Ann,l hereby certfy that the nell(s)uao(wire)constructed in accordance
7.Is tfris a repair to an existing well: Yes orpNo with!SA IICAC OW MOO or1SANGfC 02C.0200 Weil Construction Standards.and that a
IfthisIsa rrpalr,fill out imotsrr wellcvnstru 'n li armet and a plain the nature of the COPY of this rurard has been prmidedto the stalfmvaer
repair wider ff21 remarks-seuion oron the back oft isfonn.
b` 23.Site diagram or additional welt detals:
F'r. 8.For Geoprobaffer or Closed-Laop Geothermal Wells having the same You may use the back of this page to provide additional well sitedetails or well
construction,only 1 GW-I is needed.Indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: SIrBIVEZ1(•AL INSTRUCTIONS
9.Total will depth below land surface: q 2 5 (ft) 24s.For All Wells: Submit ibis form within 30
Far multiple wells list all depths ifdhfferent(example-3QZ00'end 2Qo 100) Construction to the following: days of completion of well
10.Static water level below top of casing: Ve (fr.) Division of Water Resources,Information Processing Unit,
rawer feud is above wising.ate+�•/' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole tlinat*otert f� (n) 24h.For Injection Wells: In addition to sending the form to the address in 24a
ota,c above,also submit one copy of this form within 30 days of completion of well
12.Well construction tad: construction to the following:
(i.e.auger,rotary,table,diinctpusb,etc.)
Division of Water Resom'Ce,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: ,�- 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(pro) 1VIelflod(Wiest: �l tGl I 24c.For Water SUPDIT&!Weston Wells: In addition to sending the form to
L / the address(es)above, also submit one copy of this foam within 30 days of
131,.Disinfection 13'p®: 't�T Amount~ (��� completion of well construction to the county health department of the county
,
where constructed.
FormGW-I North Carolina Dt tofEnvironmentalQuality-DivisionofWalerftes�Rces Revised2-22-2016