GW1--05017_Well Construction - GW1_20230807

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Print For,_
'WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Inrorrnatlon: }
i
:. Cameron Bann I&WA1t?RZONES .. I
Well Corae taerNaraa - FROM TO mammas
4518-A 'jao It' ft. 2 ,,,
D. tr.
NC Well entracte CmtiGntionN�laas IS.canna CASING(for mold-cased wens)ORMSR le �)
Aqua Drill,Inc. FROM TO DIAMETER Tmr�avess �L
�G
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c N - 0B. Go ' f 'a 1 _—
16.INNE m R CASING ORTUBING(geoferd dased400P) '
2.Wen GnashacHaa Berndt f✓r -(`)-- FROM To Dtnt�ltsc T ICIlNiss MATERIAL ;
Liaratta flcableedlconstructtnapasa}er(i.e.UiGCmmtty.State Variance eta) R. ft 1
3.Well Use(elteetrwell me): ft. ft in
Water Supply Well: 17.SCREWl
_••CnitII[alFROM TO DETFR SLOTS[ TRIt�CNESS MATERIAL , �.
aliricipal/Public g $ rYAM _
ailGeothemsel(Heating/Cooling Supply) dential Water Supply(angle) ft, It ta_
1.Indushial/Commereial dential Watrr Supply(abated) is.GRODT
IttipatlnIl MXIEPIAI. RO A(3:a1a0u MEZ1aOD&AMODN[
iZtObi TO
Non-Water Supply Well: o ft- -S ft G l i f�C
al Monitoring pRecovery IL a
,'ection Well: 9• ,
rt.
* • eriecherge QCaouadararerRemedation
19.NI • `5 �� 0°aY r��allnity Benier FRoesAi�ID/GRvEL PACK TO tie) �t•AC&Martr METHOD - .'.
I -"Tat DStamvraterDrainage ft
* •• .•.tabalTechnology DSebsidweeCoanol It. It.
t•
11 Geothermal(Closed Loop) ElfTlaca 20.DRQ.LLNG LOG(attach additional sheets if itelaary)
—Geothermal(Heasmy/CaolmgReGm) �thher(e><plainundaf{21 Remarks) FROM To t)FSt rilDH(mt�hardness,rawroet tIP c�•lu ee�t
2 th 0 ft' a n rieM
4.Date Well(s)Completed: 47(1A/2.5 Weli g So ft' �2S ft IL, �l. ',
5a.WlLocation: ft ft
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Fee�I 1 Jo gm�aYme l FJany IDS(ifaappltarble) ft.. n j 1.'
t I1Z +or/1 50n f,1.' J\ros- � R D l" '2.' (�± l i r' J 1`
PhysicalAddretis,Cliy. ndZip EL R "L.s 11 4 5�
21.REMARICS h Li r _ _ xy1
414( y t1vu e LUL:i
County Fatal ld .t "r S oa Na.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwvf&ld,ono latlaagisaoSeieat) 22.Certification: r,t• 3 y•�
'3e,. 36•125 IS .g9•4CFI-It w l�- �.
i.Ts(are)the well(s) ermaneat or °Temporary SgauuceofCrm'sedwetlCantrador
Sy.tigntng this fanny I hereby crrtifr that the eeif t)sear(wrier)evartruded ih am:adance
7.I5 this a repair to �sttng welt yes or I o with ISA NCACDSC_0100 or 15A NCAC 02C.0200 Welt ceemv ttan Stee rerer •
4,r-
�y and Net a
ljthis te a►epafr,Jlif eta bwwn well aourtra�vn information explain the nature of the mpyajthtr record bus been providul to t5e x ell owner.
repaUmtderWI moist iarec8on or on Ilxbackrftldrfem. iy(,
23.Sitediagramoradditionalwelldebas:
8.For Geaprobe/BPT or Clnced 3 oop Geot3rumal Wells having rho same You may use the hack of this page to provide additional well site details or well
e nsshnetion,only 1 GW-I is needed.Indicate TOTAL NUMBER of wells eonstmetion detail You may also attach additionalpages ifatxpsory,
drilled SUBMfTrM NNSrRUCTIO1VS
11
For txarrtpicwlls asks& &fray map( e-3 ' �009 ( , co construction to thea.yor Ali Welk: Su
bmit this faro within 30 days of completion of well
10.Static water level below1»[�tsabo� ng: li
tapof 0 (ft) Division of Water Resources,Information Processing Unit, rr'y,
1617 Mill Service Center,Raleigh,NC 27699-1617 g'
11.1iorrLck diameter: / (10-) 24h.)'tgrlydestlpp Welly In addition to sending the form to the address in 24a
12.WeB construction meshed: (C / above,also submit one copy of this foam within 30 days of completion of well 1.`
t ncdoa totle followinEg
Cat ear rotary,able,&mar as%ate)
Division of Water Resources,Underground
FOR WATER SUPPLY WELLS ONLY. 1636 Miii Service Center, Injection Conhrol Program ,
ae>gife NC 27d49-1636
13s.Yield m) Method ales!: l 1^� 24c o W $tlDoly do medics) on WeW,
theaddresses)above,
Also talbmit one addition tD sending the foma to
7
13h Disinfection type: Amountt 1 bli complatittn of well construction to rho c0PY he this faro within 30 drays of
•
where eoastrtret� county health depmtmett of the copoty
FomiGW.l math CcDlina Department oPEnvim�nasalQuality-Division of Wear Resources
Revised2-22-2016 '1