GW1--06611_Well Construction - GW1_20231017

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41nLiF0nn'+ y4 bi # o ' .° W+ ` s -� aw' s 4, s 4, ;1!;4 Pt a � r`, t3 ; h �lti ` - " for itenaUealyt e. UfUNRE RD(GW- 1.weft Contractor Information:
Cameron Bann - 14.WATER ZONPS_.. I. !
woncomacterNomC FROM TQ._. _ . ;.,Dzsciu noN [
9e-A 185 R. so ar°l' i
R. R.
NCWert Contractor Ont fcationNumber
15.0>3TERCASING for mnletrased wallet ORLIlN=(d lible)
Aqua DM,Inc. ia(oM TO DIAAlf,1ZR. TalciavFss MATERIALv it' g o '• G in. ' I_el(
Compony,Nasoz 16 INNER CASING ORTURING(aeelhemaieiwa 4001O
2.Wert Construction Permit ft: w0 FROM TO DIAMETER THICKNESS MATF1tML
wet (i.e.UiC.c wil.sate,Variance.etc) IL ft•
3.Well Use(chectcwell Use): ft. ft.' In.
Wolter Suppb,Well: ) 17.SCREEN ___
311 .y'culhiml FROM' TO DIAMETER SLOT SIZE TarCin�S MATERiAL
MtmictpallPablic it ft. in.
E Geothermal(Healing/CoolingSupply)/ widential Water Supply(single) ft. In.
II:Industrial/Commercial Residential Water Supply(shored)'
1e cRouT
ni ion
FROM TO MATEEIAL EMPLACEMDDRl'MEFROD&AMouNT-
Non-Water Supply Well: Q 2Y ft. G 11',4 .
*Monitoring DRecovety tt ft:
Injection Well:
OGmnndwaterltemediation
ft.
Storage endRecovery 19 SAND/GRAVELPACKiReonlieobie) •
OSabnnyBonier FROM TO MATERiAL EMPIACEMEETMErIOD
IrAquifcrTest DStoxmwaterDrainage ft ft.
D .,.�.4..entat Technology 0Subsidence Control ft. ffi
II Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach adddionolabeetoif noeasoar39
Iji Geoffiecmai(l3eatinfjCoolingRettm) �Odrer(explaiaander#21Remetlrs) FROMt TO ' DESCIDET:oN(coto,bcn .eut�aaIFF4ta+ta�.eew
Well(s)tDate7v SGyt�
4.
Completed: qI 71.$ Well IDS 7a R' 2o5 .J7,,,,jt i- ,,- -
5a.Well Location:
ft ft. , NC ( .y h,ti r�,t'
R. ft. ^r: o k.�la
racEityuh rrieme Facoity IDS C�fepplieable) it. it: 207..E
0c.�td,Ar�A Pr 7a fo(sv1�(L•
,7}J �.�r 3
Physical Address.�dy,and Zlp ft. ft, �, .J Lir,
Calmly - Parcel Identification No.(PIN) i ..
•
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(IfwCU field;ens lading issufficient)
22.Certifieatioa-
3c Clcr(Sa N 8t,2Y3` 5 .1;,
6.lis(dtre)the welI(s) Permanent or Temporary Sizes=ofCezdfied Well Contractor 2S
//�- Date
8y coung this forth,Ihereby cere that the we!/(a)sets(were)eoesMrued in accordance
7.In ibis a repatt to an exit even: I�Yea or No with ISANCACo2C.0100 orISANCAC Sic.0200 Wen Constrntion'S ,a
lfthfs hiSa Pkk)aot:"Inconsn2 .,E iafommtio and ap/ainth,no„ofdrc copl'olW ++dhas'beeninwldedtoComa owner.
fillif-3.a #1i emit lssectionor=thebackOhie
23.Site diagram or additional well debate:
8.For Geoprobe/DPT or©osed-Loop Geothermal wens having the same Yong dib s,y page tot provide additional well site details or well
dolled:
llhutdica,only1GW-lisneeded.IndicateTOTALNUMBERofwells y also attachadditioIIal pages rin
SUSSIOITALIly,4TRUC IONS
9 Total well depth below land tenefae Zd 5 (ft.)Formuldplewarfalai1depths&E erent(example-3(a2oo•andl®Ioo9 ( �acon �(befollo Submit thin 30 days of completion of well
10.Stade water level below top of casing ,, (ft)
Ijwsateriefericaboueeasing use+^ Division of Water,Reaonrces;In{ tion Pen
1617 Mail Service Center,Raleigh,NC 276994617��il.Borehole diameter: r� (in.) 246.ir"or Ieteetion;wens. is atielition to setidin
abev" also t3 form to the:
12.W�eonstrnetion method: O \/ r.Onstrualso follow*
of this form witLiu 3p d of oompl B g 11
CLe a+ +:iota%cable.arectpvsh,etc.) I
FOR WATER SUPPLY WELLS ONLY: Division of WaberResomnes,Und
i(nd M�s � 0.une LnjecblonContro1 Prague
13e.Yield(gpm) 50 iVIedtod of best: 5,f Ind 24s+For iNater SuDuly&Ynl ' '�,Nc M699-163$
l�, the add ess(es) above, also submit nee c ' addition to wadi die Earle to
13b,Disinfeedon type: t Amount: 1&ham completion of well constructionant of this f� da
w1iere constructed. to the County'health of the county
FormGW-1 North mlinaDep entofEavtoameatalQuolk1-DivisionofWaterltesca r
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