GW1--05882_Well Construction - GW1_20230918

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ti '.Print Form
tafrig ti ialR RECORD(GW l) For Internal Use Only:
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1.FO•el Contractor Information:
14.WATER ZONES I ' #
J Cameron Bo2iR FRDat DESCRI TION i
Weil ComraecnrNamo •3 f. R ZS _2 : '
i 4516--A R, ft. ft .
NCweitcoa4unorCenificationNomber 15.0[)7�RCASING(formaDllf �we11s7OR (if ll to AL
: Aqua Drill,Inc. FROMTO
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;,; � �I iron � 1 � P��
i:. CompaayName ,, 16IIV[QERCASEtGORTf3SIIBTTG(tm�e�c �Iooa)
t` / / $D 7 FROM 20 DI mErgRG : YffiC c") 'wMA.T.AL
2.Wen Contraction Permit#
Ltst all appttcable well eonrtauetion pemstu(je.UIC,County.State,Varlemee,eta) `
.' in.
.#, 3.Weil Use(checkwell use):
Water SupplyWell: 17.SCREEAi' DIAMETER •SLF7rsrze , 1 R MATERIAL
x;. FROM To
'cultural OMlmieipallPablic ft 1 ft. 1°'
' 1, Geothermal(Heating/Cooling Supply) ' •eshtential Water Supply(single) ft. i ft Ix.
IndustriaUCommercial I'Residential Water Supply(shared) 18.GROUT ' MITPLACEMENT MITMOD rr AMOUNT
Irrigation To • MATERIAL
Non-Water Sap11y Well: 0 ft i2Z- ft. C,477, S
Monitoring DRecovery ft i ft.
t InjectfonWell: R ; ft •
IL gulf' Rem erRecharge DGronadwaterediation •
t .•19.SAND/GRAVEL PACK(If opnli able)
gnifer Storage and Recovery �Sa►inityBanter MUM :TO MATERIAL1?nlrtACEeIPdrinEcrlon
AgaifotTest DSto�wata•Drainage R' ! ftcrimentalTechnology oSabsidenceControl ft ft.
r' Geothermal(Closed Loop) E3Tnicer 3o.DRILLING LOG(attach additfeml Cheats Unac )
Geothetaml(liea6ngfCoolingRetum) Other(wrplatnunder#21Remazks) FROM T/�O °�cRlvtroNlmtort+ordaec,ma/eoeur�r.taera�iZr.eeat
0 1t '9 a ft- 42z—Gi •
4.DateWell(s)Completed: b(7, 3/72WeUID# Teo R' ,;v s ft. /20 G✓'
ft. I it
Se.Well l ocation:t. •
a Pm'Ilty/OwaaxNamc rvfiniV4MCifepplicaloli)
li
't Physical Addatss,City ansZrp ..
A56 21.REMARKS : :.:r:.^2 Lira
c lam" P _10G
County • Parcel ld%mincatioallo.(PIN) �. •d:i .
1 5b.Latitude and longitude in degreeslmlauteslseconds or decimal degrees: _
l' (ifweu and,one Lenore issuffieIr)' / 22.Certification: - '
74
6473
/1„-- -- e .
6.Hs(are)the weII(a) YermaDent or oTemporatry
Slsuanua afCertified Well Caa4aamr D
!!�— By signing!his farm,I hereby aer*Oat the uII1(s)nm (wxrv)abash-acted la bem►dance
#.. 7 Is this a repair to an existing well: [JYes or o h ISA o this C 02C-0100 orISANCACOIC.O200 W�ConsbucionStardords and the a
jfihtaIsang41r MentgownwellcontractionInf and captain the nalareofthe COPY f recordhesheriamadatotketlEUowner.
Li repair,Pun.#2liannraseat=0r on the both oflldsforni Y2onSnhdluag¢IIm
sethe obrakd d[ht
of thiioa lWdeals additional R � iataalsorwe11
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LE
L For Geoprobe/D/iTorClosedLoopGeohermaW?lisaing the same
conshnettea,only1 GW-1 is needed.lndicateTOTALRitedBlattofwells cousttucaondaa7s YaumaYa]so e tadditionalpagesifiue, 1f%
dolled S[T�!}�l$�QII.AIl36fRIICi7(oR79
9 Total well depth below land surface: 3" ( ) 24a.For ill.We1Es: Submit this form within 30 days of coDi letio>s •
Fbrmulgple wells list al1deplhsrgifermtt( ple-goo*mrdzagaa1 coialtuictiontothefollowing: P of Nell
•` 1®.Stark waterlevel belowtop of ofthtg: (ft) Division of-Water Resources,Yflformatlotl
t, Ifioterkvetftabovecmt?guse+" 1617MallServiceCenter, �aoccsshagl)lllk,
,DIC 27699-1617
It Borehole dfamefer: Cot) 241t. Dr InlecGon We1ta: .III addition to sending the form to the
: ,(a. '? an0,4*n tote i lle cinY of this form-within 0 days of c°mpl of well
g�We® Dstruddon tDe>botl: 3
Cie.auk,m % d°� ,ere.) I.
Divisiote of Water m�Unfi
FC18 V'dA SUPPLY WELLS ONLY!: 1 fi S d la9ed3o4 Coffit)oq_i°ro
ervi�Cenhr;ItaldP,b,NC:E7r1 f,3t g�tm,
BletitDd oftes� ,It r
&3d.Yield(gp:°) Z �, 'ectl® ells:
e. Zq the above,also.sahurit D° sending
Amount: o9 comPl �well construction to.theoy°cop f this the fforol Y4
;:136.131shAffe
.°Q where constructed. ' -dainty health der 30 Sys of
North Carolina Department ofPnvitonmenml Quality-DivivionofWaterR �t county
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Farm s(1pJ-P itetnsod 2-2Z Z916