GW1--06669_Well Construction - GW1_20231006

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1.WeD ContaactorFDfirmaUon:
Cameron 88�R 14.WArARZONES
Weil Contractor Name FROet 'n0 DESCRIPTION I
4�9s a Ig 5 IL ,p�J ,
R. rt. I
NC Well Contractor Cettificadon Number
15,OUTER CASING for ma ltiaased write)ORL1NKR Mu lteable)
Aqua Drip,Inc. FROM To DIAMETER TWCKNESS twwTERrAL
CompanyNotoe —7 it. O ft G �'I� ��
- 2.WellConstructionPesmitI o/ OmMtNEttQ RUGORTUBIN et� )ESS 1 MATERIAL
MDalLepp&DMe itco srnreltonpemelle(Le.UI(ti Covn0.Stale,Variance etc,) St
wit ta.,
3.Well Use(check well use): ft. ft In.
WaturSuppI Well:
a 11.SCREEN _J
Itt'Agricultural OMunieipaVPnblic MOM TO DIAMETER SIATSIZE THICKNESS MATERIAL
f. ®,
'Geoihe[mel(Heating/Cooling Supply) estdenffal Water Supply(single)
llndustrial/Commercial ft. to
Residential Water Supply(shared) I&GROUT -
�� on FROM TO MATERIAL — EMPLACEMENT METHOD&AMOUNT
gati
Non-Water Supply Well;
A:Monitoring C7 2V ft Z.1+��
Injection Well: I�!Recovery E=�.
al•quifer Recharge It ft
E3Cuo ntdwateai(emediation
- 'Aquifer Storage and Recovery °SalinityBatrier FRORANDIGRTVELPAC _(ifM TP Le)
*Aquifer Test _ EMPLACEMENTtnErnoD
DStoannvaterDrainage ft. ft
NI ••••• .anal Technology °Subsidence Control ft. ft
nI Geothermal(Closed Loop) E-(,Tracer 20.DRILLING LOG(attach ndEttond attests tfnecessary)
ti o
Geothermal(HeatinpJCoaliogRetum) Udta(explainunder#2iRemarks) FROM TO Dr/sCRlQsON(mlar,haomm.,aarewcestwu+in>d�ete)
•
4.Date Weil(s)Completed: +'/2Ol/1,1, Well Mir D `5 f 7
7o ft' 2d7t' 'J r
Si Well Location: It ft. It 1:.,3 T� ,
• Oa.kill-00cl 6,-1 a7"d 8 ft 7....„.r1 'q: I.. t..
Factity/QamerName Facility lDllCfopplirable) ft ft
O(� !,{ � OCTA6 ��23
rAnciv i ,1- Pr laylo(Sval((_ ft. R.
PhysicalAddress,Crrty,andrp R. iL lcrvrn :I . r F,mow
!-i�t.�C(q:t�),� 21.REMARKS R+.., '``'3 t't -
County • ParcelIdentifcation No.(PM)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Gfsvell field.one letl[ong is sufficient) 22.Certification: t
35, f S 1,4 81 r 2Y 39-5 w —L..•--`
6;Istare)the well(s) Permanent or °Temporary Signature ofCetufitttl Well Contracts S
Date
Sy signing this form,I hereby cerrg.that the r rll(s)was(wero)co strue:a in acco
7.Is this a repair to an existing wen! Yes or No
"wrist, with ISA NCrtC oZC.0100 or ISA NCAC 02C.0200 WeilWeilConstruction Stared rtiance
Uririst,repalrfir(out wellconnlructioninformatm andexplaitthenatureofthe copyoflie record has been pmvidedtothewellamen
a�`Qt�r> a
npalrunder#2!rernarla section or on the backofthirfo
23.Site diagram or addidonal well details:
3.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may us&the back of this page to provide r:dditIonal Well site details or well
construction,only 1 G W I is needed.Indicate TOTAL NUMBER.of wells construction details.You may also attach additional pages ifuecessoly.
drilled: SUBi@fl ITAIL INSTRUCTIONS
of completion 2
9.Total well depth below sand surface: d
For mulaple wells['stall ( ) 240.For All VNells: Submit this form within 30 days of well
deltas iffirent(eramp([e-mail]0)
constructionYatllefo!(owing:
lg.Static water level below top a-casing: S f.
Ijaaarer level u above casing use"+" (ft.) Dlvislon of Water Y Resources Ini'omaadoa processing U��
fl637 Mall Service Center lRulelgh,NC 276991617
II.Borehole diameter: o Om)
24b.For Fn a don P!!eD
above p�additionorrmsendinl g the form to the address in 24a
fl2.wen construction method: Q Gf�/ ,also submit one co of within 30 days(ie.aaro,rotary,cable,directpasb,etc.) j coa'tntetion to the following, of eomPletioD of well
i
FOR WATER SUPPLY WELLS ONLY: Division of Water P.esour
oes.YTndergraatn:Inadjdiliectiono71169:009:eni63:n13a.Yield m f6J61V<(a¢7:ceServico Center;Raleh,NC 21FrogrngtD.
�P ) 5 0 L Method of last: 5{GI Ltd24r.For Waflab.Disinfection tape: r�� Amount: 6�J�! chomplehan ofw bello, also lDone copy of ng the 0 forpt to
FormGW-i where constricted. construction to the county heaUh dep—u s f ri.LWI of the county(14
North Carolina Department of Mohammad Quality-Division of Water Resources