GW1--05355_Well Construction - GW1_20230818

kS 4 c i.. For Internal Use Only:
IComltnetorinfpm/Wien:
L Camera14.WATER ZONES
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Well Contractor GSrtifiralioalloa�hcr 14 0117PHfIC�1S411G` Costaoiii�^?.:3cry1)QA�. sit' = i
Aqua Drill,inc. _ =L?
Coaga+a9Atmme fl c� 16.INN...av C c GR IMINGCrzrte mtli cla^F1'^_^;,? n. .r.,___ _
2.Well Con>struetion Peffitik .r0 rS 1Z FROM TO ,J ou+r, R ' aiia,-ecs 1_-____ _--
ff, to
List all applicable nail eansmrCfanlramits(i.e.UIC, :State YariaaCti etc) it i
3-Well Use((Inkwell use): ft. ft,i !��._
IT_SCE4E1 1
WaterSrrg►g�yWell: FROM TO M.,A E, SLUMUZF. 7-r:ta4*:.S i7n.,�a�.:.:..--1
X ,•culbual DMnnicipallPoblic It. ft, 'D h •
;
'Geothermal(fleating/CooIing Supply) ' -.'dendil.Water Supply(single) R. ft. tl. 1� 1_
I. I I IadustrilUCo mnemial ;_'Residential Water Supply(shared) is.GttOOT -z
it •- .en FROM TO ' MATERIAL Er+i4:../s017.1EFIT 'vle:i4.01::,:::,.,_=:'=1, i
Non-Water Supply Well: 0 't Z G1,;`,! ~'
11111 onitoring DRecovery ft. ft, _..__ t
injection Well: It. ft. ,
ale•golfer Recharge 'OGrouadwaterRemediation _ _. -
19.SAND1Gi3A`tEL FAME applicable)
-, ,K Storage and Recovery DSeliaity Barris �
rl MP FROM TO MAl '411L 3 As a..•MT,:- ;
••, 'erTest 0Stommater'Drainage
, II ..„ ;,,,cntalTexhnrslogy DSabsidence Control ft. ft. —.
I I;Geothermal(Closed Loop) .OITlacer 20.DREG LING LOG(attnc3s esletioaal&seats i5='-•c )
f FROM 1 TO IMMCRIFrtmrd(clr hn:carem,tr.:Fr atcps gc'-n==7=,=_- ::;__-__I
I Geothermal(fieattaglcooling Rehcm) nether(explain under#21 Remarks) RO r- �S ft. /
a,.)..-1 i
4.Dote Well(s)Comp?e:pd: 7/ZQ2;Yen ERN i fP' }3°1 fr. dS£7�t, _ i
ff. ft.
5a.Wef Location: i
t�icon AS Lae/ • ft. ' ft. e _ -t
Fneiit#OvraerName FacaityID#(if applicable) R' I' o t
i ft. If �Q.�ii� !V�i �,:�
ft. .
PhysicalvAtkIzcss,City z� • 21 REMARKS N 11 i i 1 _._51171i�f��L �n 1
fin, . Parcel Identification No.(PIN) irnvriraI.'.:n t-r^G P' r:•
511.Latitude end longitude in do„„ree5lminutes/sezonde or decimal degrees:
Orwell field.one latileng1s sufficient) 22.CertificatIoa:
5 K 2 5 5 VS n e o4`1,7i,oi w :»
- ---J--•—_ -.Z6--i-q4--A.
Signature of Cab Well Contractor D :
6.Ware)the well(s)��prQrmaatut or °Temporary
TBy signing this form,I ketch),caul.that the u ll(r)USES(Wale)Cmstruae i �:c:resu.ce
an�, yes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.02C0 Wen Construction Star_% -: ::if.:s
7.is this a repairo this record has beengra.-dud to she can tovmw
!fads is a repain,fl l out bwivn well cam rucBaa Worsen& and mile&the nature of the COPY I
repair under#21 remark section or on the beckofthief 23.Site diagram or additional well deiat6e:
You may used=back of this page to gnat&eY ti�zri v€:"sit,;:de':a.>'=or well
g.For Geoprobe/DPT or Closed-Loop Geothermal Wells having then same cansttut lion details You may also attach ar,l:tc psi gages r c surJ-
enostmdioli,only 1 GW-1 is needed- Indicate TOTAL NUMBER.0f wells
drilled: ,SUlilVll'ATAL EId197'IFETQ:lCA(i S
9.Total we l depth below land surfnee: 30 D 5 (D•) 24a.Far All Wear. Submit this faint within 30 days of completion of well
For mulaplsleris list ail depths f.D (=ample-3©200'and 2@100) constntctitu to the following:
10.Static water level below lop of easing: Vo (ft) Division of Water Recourse,,rufformeion Pron:ssing Url,�
Jimmy lewd is above casing.use+- 1617 Mail Service Center,Raleigh,NC 27E9 -1617
11.Dort-bole diameter: v (1Q) 24b.For lulectiou Wells: In addition to sanding the form to the of u s 32.24.7.
above,also submit ono copy of this fora width:30 days of completion of well
12.Well construction method: rco `Gtr construction to the following. •
C,a.ngn rmuty,able,directptitsh,ate) Division of Water Resources,Underground Eni ton Centel 3 r`g area,
FOR WATER SUPPLY WF1I S ONLY: / 1636 Ma Service Center,Raleigh,NC 27699-1636
13s.Weld(gpm) 2 S Method of tub 5./'Mils 24c.For Water Supply&Erixtiom Wells: In addition to sending le form to
the address(e) shove,also submit one copy of this form within 30 days of
13b.Disinfection type: IR rY�q Amount /6107- completion of well construction to the county hcalfit department of the emmly
where constructed.
Fuca ,(-W-I North Carolina Depitooeat of Eavitoamtnml QaaHty-Division of Water Rasourc s M ul 2-2 2ill6