GW1-2022-04026_Well Construction - GW1_20220422

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i►�LL CONDUCTION RECORD(GQ6i-11
For Intemal Use Only.
L.Weil Contractor Information:
Cameron Bazin U WATER'ZONES',• DEs ODI_
FROM TO
ft 3�S it r
Well CantraetarNam %e p —
7
4r A (�, rt:
15:OVTER.CA9PIG ormulti-rased-wells`OItL1IdER rfa' Iir�lile =
NC V ell Contrsclor CetRScafmnNumbcr n R TSICKi�ss T L
FROM TO
Aqua Dn11,Inc. n' tt In'
-
CompanyNatne :16.IPlM rAMG ORZ pBING eotbestaal dosed lou i
(� DIAMEIHR �C(¢IPSS dLATERIAL_
TO �.
' 2.WellConstruc6onPermitp-: n �� tr, fL
fist all applicable adl construction permits(Le.UIC.Coun%Stare,I'ariance,etc)
R. ft. I
3.W eAUse(checkwell use):
i SCtEFN '` - SLr11':i1ZE 7HICIOH£SS. ]VIATERfAL
U
rROM TO DIAMETER
DMunicipal/Public R.
nglCoormg Supply) ! dential Water Supply(single) fL ft Sa
_ rcial- dential Water Supply(shared) I&GROUT
- - - FROM TO MATHtIAL--- Fl`fpLACE vroj r MUMOD&AMOUNT-
lNon-watet:sIlPe1y we1L O % 2 Ll
Monrtormg [3Itecovery R. ft
F
: g j
barge EiGroundwaterRemediation
19.SAND/GRAVELPACK d.a liable .
t^ age midRecovery 'OSalinity Barrier FROM .TO MATER7AI. EM;q AcmmrENT•METEOD
tOStoanwaterDrainagel Technology DSubsiControl tL(CloscdLoop) �Tmcer 20:DRILLINGLOG attach.additional strca;ifn- .`
Geothermal(HeatinglCoo' Retain) (explain under#21'Remarks) FROM TO DFscRrPnoN(a,tnr lard.—ml/rocic a to
-
!L it
S Date Well(s)Completed: 2 Z 24'ell1D# o R ? 5 1L f = }
5e.Well Location: ft. IL
y ++� C fft. fL I GO +TV l Lori _ a rr nMr
Facrliry/Owner Naam RciQty,1D9(if applicable) R. ft. ff_J
fo?( M,&b�>N.)I Ln >7Ak,„vi'444,'L R. ft. = i
Physical AM—.may.and Zip ft. It. —
7.1.REA ARILS _
cane. Parcel Identification No.(PIN) l
5b.Latitude and longitude in degrea/minutes/seconds or decimal degrees:
(fvnn field,one kviong is suf view) 22.Certification:
3 . lo�� N e�r G312r'�
W /In .y Z
6.Is(am)the well(s) ermanent 'or DTemporsuy Si mco o Nell Contractor — Uarc
!
By sibmlr g thir form.I hereby—,fy char be avelll'r)r+as(acre)eoaffluaed in accordance
7.15 this a repair to an existing well; MYes or No with 1SA NCAC 02C.0100 ar•13A NCAC 02C.1a205 Wa Caratrucdaa Standards and that
Ifilris is a repak Jill outlm m troll cmubvcdon Itj 0=V1nn erplaln the nature of the copy of this record har.bam provided to die welfmvrrer .
repair.under 921 nsaurbserthm or an the back ofthis farm.
- - -23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop 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 TOTALNUMBER of wells construction details.You may also attach additional pages if necessary.
dolled SUBMITTAL INSTRUCTIONS '
9 Total well depth below Sand surface: 70- ( ) 3
FarmuGsplcnelLrBs(al7depthsifdi�ermt(example-3t�2D11'and1�1Q07 24a.For All Wells: Submit this;form Milhip 30 days of completion of well-
constmction to the following:,
10.Biotic crater level below top of casing: Sri (ft) Division of Water Resources,Information Processing Unit,
Ijtvaterlevef is above casfa�use+" 1617MOR Service Centei,•Raleigh,.NC 27699d617
]L Borehole diameter On.)
pn.) 24b.Forinleetinn Wells :In addition to sending the form to the address in 24a
12 Wen construction method: �q���1/ above,also submit one copy of this foray within 30 days of completion of well '
•CLe.auger,rotary,cable,direct push.�-) construction to Cite following .
'Division of Water Resources,Underf;round Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of tat:- � t/��,,r 24u For Water Sunnly-&1"lectiOn Wells; In addition to sending the form to
the ada=Res) above, also submit one!cojpy of this form 11viihin 30 days of
13b.Diabafection type: E , Amount: 'I®7i. completion of well,constraction ro the county health departrnmt of,the county
where constructed.
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