GW1--05490_Well Construction - GW1_20230825

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1 runt Form
I'Well contractor Inrnrtaafl°p, Gw 1 For Internal Use Only: __ _
Cameron Bazin
Well Name _ _____ZONES _
4518 AFL To—nrscaa norl —
" NC Well erorCalifiatioaNumhcr it ft. i�-�
_� Aqua Drill,Inc. • IS.oIJl@t
V [TtON ettsiNc�mD ea:redweUs}SOAL1NEg Cdappye)
y.Nam e r
n t mamas MATET .r
CoMPSIl2,well Caats@r+scHolt Pecffiit#; . /1J— 5 I P!�
•
aaartrurllaAperau[t rt UtC, ' statg Yarhmcq etc) DIAMETER TRIMNESS MATERIAL
3.well Use(check well use): Ia.
Waters ft. ft. fa
app7,yw en:
17.SCREEN
ElMonicipal/Pualic FROM TO _ DIAMETER SLOT EWE THICKNESS I MATERIAL
Ge9thatnal(HeatinWCoallagS 0. ft In.
apply) Idential Water Supply(single)
IniustrisUCommerciel R ft. to
Iai 'on
lccesideatial Water Supply( 18 GROOT
Non-Water Supply Well: FROM To • MATERIAL EMPLACeMBNTDffiffioD&AIMIODNT
Monitoring '? R
Injection ell:
Recftft. G�1 5'
�GraaadwaterRemtsiiiaation ' •
r Storage and Recovery D5aliaaY Bonier 19.SAND/oRAVEL PAcKOf applteehle)
�,� L.! FT1OM TO M.FRU& EMrLACEMFm MEraon '
OStormwaterDraimge tt RIntaiTecHavlogy 0SabsideuceCaaanl R A Geothermal 1(ClosedLoop) E3Tracer 2a.DRILLING LOG Wrath additional oteem tf necessary)
ttfl ICOoliagliepalt) Offia(wcplaiauadertk2l Remarks) FROM m D>SetRIPTION(mine,lmrdn®..durmrha,vs%ster-do.)
4.Date WeU(s)Completed: -5/&/S well IDf# qft. s5/� "Kj °•2 S ft.
L q�
Sa.Well Lunation:
Of;av b it. ft. ' L.L L.
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�o ey t o V P
Facility/Owner Name FacilityZD#(if applicablle)( n• 2
(Q`a G�Gt eiN l'(`n t i t Z� /G A ileAvOt-•
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Physical Address,City,aadrip / J ft. tE -
�� 1A I1.REM4BRS IIt Ar+mNfi^n rar.*rryS pO l ire$}
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Cmmly Patn1ldeatiHattoa No.(PRY)
5b.Latitude and longitude la degreeslminutesfseconda or decimal degrees:
(if w ID ICI '1�4�sufficient)
PtS, f79��I w 2LCertdicaHon:
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,la .— /4/
6.Is(are)the wells) Permaaeat or ElTemporary Dose.
// By*wag this fain I hereby are fy that Ma well(s)Inn(.velar)constructed In acmrdmrco
7.Li this a 7epai to tan existing well: t�Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200+Yell Construct Standards and that o
Ifddr it a►rpal,fill out lama well construction bfanaa' ad clean the nature of the coPY Ofthis record has been provtded to the Neil aware.
gtalrL!er#21 rmlmfssction ar=the back ethic" .
23.Site diagram or additiom1 well dew
S.Ir o�prabe/D W�1 isaeedod 7ndltxte TOTALWells IVUMBvin
g the same
only 1 pages ifnecea
ofwa You may use'the.back this _additional!mil site details or
muustmaioada*ila YouIDaof psbry.
Od SUBIVUT1'AL�IN4TRUCOONS
drill9.Total well depth below land surface: 2-2 (0.) 24a.For All Wells: Submit this foam within 30 days of completion of well
Formu(dple villa list all depths jfd err+(e rVIE-3@200'and2@l00) canshncfion to the following
10.Static water level below top of cooing: �v (0.) Division of Water Resources,cos, Raleigh,1617 Mal!Service Center,Raleigh,NC 276991617
IL$orehole dla motor•. {m) 24b-)for Ialcetioa Wetla: >a addition to
��•ct- above,also submit one copy of this form sendingn the
form to the address is 24a
12 Well canatrr+sUon mod:�) v construction to the following of completion of well
ox.ante,raw, l0.
Division of Water Resources,Underground ID
{ FOR WATER SUPPLY WELLS ONLY: 1p6 Man Center, )ectlan Control program
{ Raleigh,NC 27699�-1636
13a.Yield(faun) 2-0 Method of test: 1 r t r 24c.For Water Supply&Iglecdon Weals: la addition to
the addrors(tn) above,also submit one copy of this farm trading the.to
136.Dislafectioa type: C,l t it Amount- fl� r
" completion of well construction to the county health depat 3D days of
_ wberecoastmcted. the county
Prom _l North CnolinaDeputmeatofEavirommeotalQuality-DivbionofWoterReromrss
Rev 2-22d016