GW1--04666_Well Construction - GW1_20230721

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0 •1 Print Forme GW-1 Far7abemalUse Only.
1•Well C.auba�rinformstiare I
Cameron Bazin
Well ContractrNomr 14 WATER VMS
4518 A mom sv nnznrrr►oea
36i lt 3o dh
N CPIell CaatractorCertitionNumhQ <G
ft.
Aqua Drill Inc. le.OUTER CASINC(for ft._mdtieased was)ORLIl�IBR fan liable)
coulp R` 9 R. TO oteenT1 R lid THICKNESs 1 mAT •
2.
Caustedetiou
�t all�irppl y 'fl l Z 1I6 momE R CASING OR TUBING eeutteut21 dwell-low ,,_' ..' '
F�aflsae:!lIC,Coung.s1arG'Yarr_ __ rt.
t TO nuteErER cF NEss MATERIAL "
3.Well Use( we11 use): tz in Tau
�'�'SaPpkPWell:- = rt. in.
caltalnl - r 17.SCREW
( 'a[ -�� cipaUPubliC FROM To ®LtMsrER— SLOT SIZE THICKNESS MATERIAL
Cooliei hupp 7)" .f ,Reside tialWaterS I (single)
Fai va . , IT Residential Water Supply(shored) 18.GRoler
Nola-W U*Supply Welk - -
_ FROM TO MATERIAL EmPI.ACElo TMETHon&AMOUNr
otutoring. IL
Injection Wed: Recovery 4 tl,s
R. ft.
Aquifer R
�fet'Storage and ltecov � erReaiest'iatian a. a
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• TO MATERIALEMFt.ACEMErrMErnOD
Paim�falTechanlogy O water Drainage n IL
Geothelaaai(Closed ) °�+ 3u1utt>sidr�ce Camiok' ft.• 20:DRILLING LOG(attachadditiomishtetsitneassar)
Geothermal eatin Conlin Retain Other lainuader#21 Remarks EOM • To MOH:PtmN(�r O '�� hace�san7jedckp4taaloel$.eteJ
4.Date Weill*Completed: �jft.ell 1
Sa.WellLopSan: � � I
Faclty/OwnerNeme ► a j V .L°
Fac714 Dff(ii MPlieable) R- It
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Physical A •�1 t 5 /,d It, t iOr AA R' a
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ddrtss,City,aadrap rt. ft.
/tiT ly 21:ItE6lARKS alum 1)rnc,460:,..A1).nit.
County R��x'1,
ParcelldewificapanNo.(PM)
5b.Latitude and longitude in degrees/oalnutes/seconds or decimal degrees:
(if well field,ono O
is su>Beimi) • .:
/!O • �7SS© IV 2Z.CerHficaflan: .
Y, . 5o� . vd *5____
6.7s(are)the wElI(s) ermaneat or °Temporary . Siguan�io Ce mEed wellCen r
7.7s this a repair to an existing well: Yes or ►Yo. Nth IISANCdthiCO2C IO Array J dor c"Z(s•'� N ti or ISANCAC 02C.010 Well )0Oon Sit yed:(n mid
tha ea
trims isarrpair,Jlll out bum/ elloombod[anit ormation egearniheaawa°jibe, m7Yojthis+cmrdliasbeeatheme/fowler. :srandardr
repair widerOZ1 nmarifasection or on the backojhhislarm. pmvldedta mal that o
23.Site diagram or additional Well defnl{s:-
S.For Geoprobe/OFT or Closed-Loop Geothermal Wells having the same corlmttuch'oa d the. Yonmay Page
to de additional well site dews or won
construction,only I(3W-I is needed.indicate TOTALNE/WMofweRs additional
drilled: Pages lflieceyr
9_13z2mTAL INSTRRIarrnw ,"
9 Total well depth 6elaw land steam
. bos.
Formaldprewelrs/bt lidepths;t4 eruza�pk-3@200•and26000
( ) 24a.Foe All�Ve]IO y
form within 30.days of completion of well
24a.F e A to the folioSubm
10.Stade water level be/ow top of casing: /O ( )
Ij:wrer tevrl u above dog use+" Division of Waterltee Ce
1617 Mall Seri*C InformationleigNPro 7
Il.Borehole diameter. fv (In) NC ZTfi94=16I'f
•
246.For 7alectL
12.Well construction method: Co�G(V abovS also sublbit s In addition to
py,of tins fit 30e m to the address. y l$ I
(i.e.anger,notary.able, per,,err) construction Won tote fPllowing of comFltxiaD of well
Division of Water
FOR WATER SUPPLY WELLS ONLYRenames;IIadergrni�d
1636/VIA Service Center drat' i--.ControlPrage
13a.Yield(gpm) 1,o . . Method oftesk Gf f/�l�� 24e.F ,NC 27699.1636
1 or VYuater$aDaiv Yni oD Wei: rti
13b.Disinfection e:-- �1 tbe.eddless(es)above;�, Oae In addition to send- the
Amount v of— completion of well construction to co*of this form'wilbin 3p focm '
winceeonatmeted tl'O county heaI@t dap i�thedBYs ok
linty i
FormGW-t NotthCarolina Department ofEovimmomtol,Q iy^DivisinaofwaterRamnces .
Rtv 2.22d016
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