GW1--04121_Well Construction - GW1_20230623

Y .,ICONS UCTI,1N ;"I CO!:). ( .Il1 I For Internal Use Only:
1.Well Contractor Information:
Cameron Bazin
im.WATER ZOnlss - E •
Weil Con racterNamc FROM Dt DESCRIPTION --
4516-A n
NC I►ellContmatorCeslaficationNumb
:15.O011 CASING(for mntti cased wells)ORLEV ROf" 1 . .
Aqua®frill,inc. FROM TO :o I� mamas y, t.
CompanyName 50 elf
¢.,182( 16.1NNERCASINGOIi T171lII�tG churl-loop).
2.Wen Cotas�ction PROM TO Mots= TPI S term
List appiieable asliconsafee iaspamiis(ii e.Ufa Casa+!*.Sate:Variance,eta) ft. f. In.
3.Well Use(Cherawe&use): ' ft ft in.
Water Supply Well: .17.
? ticuthtral FROM To aTMPaTER st.ors 2u Ttt1Ct{NtSS MAT6�AL
Municipal/Public t. ft. , in.
N Geothermal(Deating/CoolingSupply) -7Rresidentiul Water Supply(single) IL.. ft. in.
i Industrial/Commercial !o�Residential Water Supply(shared)
1s.GROUP. . . -
i3lsi;-dun -
FRQb! 'TV nrAxERTAt. MUTACEMOIVETII011&AMOUNT
Non-Water.SopplyWen: Q I 2Z- '• - ,/'S
ii Monitoring °Recovery ft. n
.Injection Well:
al . iferRech R. it -
°Groundwater Remernation
u golfer Storage and Recovery °SafergeSt inity Hairier snobs .rGRAv1 PACKjEtaopticuble) ,+Caatavebr OD
li •.. 'anon! TO b7e.TaormT_
�Stm water Drainage n n
Experimental Teeboology °Subsidence Control tl+
t'seothern►al(Closed Loop) _20.DRIII3PiGLOC(atmeticddtttoeat sheets ifaecessoiTi- -
Geothermal(ileatu' g/CoolingRe6nm) fOther(explainnnder#f21Remarks) FROM ..:- s° D//1 rroNemmr,[nraaas: WIee tyase.�so.etet
n o I 7�Grd .. .
4.Date Well(s).Completed: s( /2- Well1ng Tel :et05 -ft lYl
5a.Well itracatiort: --
ft. : N:4: :tt�^r:
or` {tom`} qw�C6��,//� Q ' -."
Y/ L\ t"JV V ft. tY -
►Nl-';Neu racTity Metapplizatle) tz JUtti' ��023
is
;�ael oo�t rl Seca � t'� f ln,S;r �',..,i
Physical Address Co,,andZip fL` ; �' *;; ig. i
county Parcel Identifeatiaallo.(PIN)
Sb.I,atitode and longitude in degrees/minutes/seconds or [e-mail]:
(If wen field,one lavtoag is sufficient) 22.Certification: '
5,f/ x. 72.3
t =. 6.Is(are)the eveII{s)412 Permanent or 3Temporary SiseaeueoFead led well Contractor Date
cam' 8y signing this fort.I hereby c n 'that she eels)me(were)ca ntruetsd in accordance
': 7.Is this a repair ,an existing will: IJYes or No with 154 NCACO2C.0100 orISANCAC 02CA2a0 Well CansinteNua Standards and a
ffflris is a repot,:fill out blown well coednwtion infornat- sod explain the nature ofthe copy ofthis record has hart provided to the 1mdI omen.
mash•tinder 6`21 srmorfss, Ran or on the hash ofthisform. 23.Site diagram or additional well Owareq;
S.For GeoprolteMP F or nosed-d oep Ceothetaal Wells having the same You may use the back of this page to provide additional well site details or well
construction,onlyl GW I is needed. Indicate TOTAL NUMBER ofwens construction details.You may also attach.additional pagesifierassery.
drilled: SURNSI 11i#,II..Rt1S'1'EtUoP ows
9 Tota➢well depth below laud serfoam lo" (ft) 24a.For.All Wa sit Submit this form within 30 days
For multiple wells list all deistic fid fferetd(example-3®200'aad 2®!oD`) construction to the following of completion of well
10.Static water Fevel below top of easing: (ft-) Division of Water ReSeu
Ifrwter fewark above easing,use"+" 1617 Mall Service Center,,Raleigh,on Pr 69 - Unit,
/' IVC Z76991617
11.Borehole diameter: (a (i0) 20,For:3raleetion.Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: in**Al eY construction to the following:
(is.auger,notary,cable,dihcetpush,etc.)
Division of Water Resources,Undergo:and infection Control Program,
FOR WATER SUPPLY Vl .SONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.)veld(gpm) °i(i/ Method of test: 24s.For Water Snooty&lideetion Walls: In addition to sending the form to
the address(es)above,also submit one copy of this foam within 30 days of
13b.Disinfection type: Amount: •
when:completion construction to the county health department of the county
Form GW-1 North Carolina Department of Environmental Quality-Divisianof Watt:Resumes Revised 2-22 2A16