GW1--06265_Well Construction - GW1_20230926

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'WELL CONSTRUCTION RECORD(GW-11 It For Internal Use Only: 1
L Well Contractor information:
i Cameron Bazin IQ.wATER VATS
{ Well Coaaacim'Namc - PROM TO rCIttP'rtOd
4518-A �6d R. , S
NCWellConhtetasCefifialiaaNumber -
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Aqua Drill,Inc. isOUTER CASING(for mnut trile)oR aaauawTsFROM tuAL
CName TO I �✓.
a R• Ii25 � 6
16.1NNER CASING ORT OBfNC Cocothermalotmedlooa) mA aarAL
2.W penult#: 3.`T 1 3 —I—ROMTO DtAtitE1Y8�. TBlt9QtP8S
Vigicable well aa+tlrtaAangmNtr(ix.Utt«Comm Stara rarfmrcq eta) ft. ft.
3.Well Use(check well use): ft. ft.
• Water Supply Well: 17.SCREEN
0Agricultund y FROM TO DiAMR Ein sums= TiDcKlass MATERIAL
iJ�t1�Ds1(Beating/Cooling ©MmtteiPalrPttblie � � la.
SuPPIy) al WaterSupp(y(single) &I R I In.
OIndustial(Commaeial / ResidentialWater&WPPly(sbmed)
OLgua,� I&GHUDT _
r.Nr�.,bOII-W`a'`°Y`tQ FROM TO • MATERLtL Ea7PLACCEER7'6fE[l[OD dcAMO1II�R'
Supply , 1 2z- C1405
QMonittniog °Recovery ft.
Ig lleee loon Well: ft U.
DA IUIferReratarre DGtoundwaterRemediatian
DAgoi£erStomgeaml 19.SAND,GRAVEL PACK r able) •
�y QSetinityBeQier FROM TO MATERIAL ,rmiLAcime rrocraon
quifQT DStomtwaterDraiaage U. It
crimeatalTechnology oSobsideace Conaol N. N.
- GeOthumm1(Closed Loop) Cimicer 20 DRILLEaG LOG(attach ad3dlambehedsifnecessity)
l(i g1CooliogRetom) Other(wrpbtinuodet#21 Remarks) FROM TD nFseRm[toNtmtm nanmmenPtwedwchce e+�ttm del
a R 115 ft. SGytei
4.DatnWell(s)Complcted: 7/1/i?j WeIID)# +,(S R Sas " Rorik
n
Sa.we/nLocaflon: t�—• �'41 a' �
ft. ft.
Faality/l)wna FseiWymucrappGeable) ft. U.
IW/74; :�. /�,t/,t,i •rs t it 6/,�f.�.e-, ft. SEP r 6' 202�
la
PhgstalAddtcss,ctly,mtdTsp � m �:�zr lh
A 1(��ti�M jt 21.1tEMAB1cs it ..
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Colmty FatcelIdemtficatio do-(PIN)
5b.Latitude end lengt :deb degreedminuteslseeoads or decimal degrees: 1
(ifwcr field,onalatMng is ane�t) 22.Certification: 1
3 szer 5Y3 N .go, <'3' &
6.Is(are)the wea(a) etnsmettt or QTemparasy SigutamofCemfied Well Contractor Date
By stgnlag thtrjomr.I hereby cert0 that the aelf(s)iins(seem)eaastraaed fa accordance
7.Ts this a to an existing well: DI Yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well ConstracHoa Standards and that a
Ifthfuarepa/r,jiBurdlaonnwelleoatructionfrfoomott apla nthendareofthe MO'Ofth(rreoonthea been provided to Octal!omen
repair wafer ff21 remmLr section aron the back offhfja
23.Site diagram or additional well dehslls:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may usethe back of this page to provide additional well site details or well
coast Radon,only IGW-llsneeded btdieatoTOTALNThgBERofwells constnutiondetails.You may also attach additionalpages ifnecessaty.
SUBMITTAL INSTRUCTIONS
9 Total well depth below land surface: CO
Aartrode!pleriel/rllrtafldepthefJdr�rmt(ewmylt-3Q20D•aadz®1oa) (ft) 24a.For All W Submit this farm within 30 days of completion of well
construction to the following:
1Q.Staticwaterlevelbelawt pofeasing: <O (ft) DlvislonoiwaterResour
"weer feedirabereearieg are+" cessloformatlon Prot e4singUplt,
1617 Mail Servlen Ceutea,Raleigh,NC M699=1617
I1.Boreboledhtmeleav (Id) 246 ForinlectLnn W n• f
— . Ta addition to sending the form to the 12.Well construction method: 6� r� me.also submrt one copy eels form witlim 30 in 24a
(Le.o rotary,cable,extort push,eta-) cottsMuctiu,t zo tbofollowhtg i of completion of well
FOR WATER SUPPLY WELLS ONLY: Divmi�"Water Resources,lilndergttio
J S 1at6 sNC2u99
13a.Yield(Rpm) t a Method of tetk 24G For water S S Ca Imo,NC Z769g.11 program.
Lsubmitn u n t 1 addition to s
136.Diatnfeetdon a the addrers(es)abo
type: �LV Amottnk completon of well� ��mu
aOPy�of tLiy form �g�form to
where constructed. CO chon t0 the eonoly h U days the comitytyty
Farm GW-1 NorthGmlinaDepatnuntofEoviminneamlQtality'-DivisionofWaterRrsoutces 1
1 Revised 222-2016 •'
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