GW1--05567_Well Construction - GW1_20230825

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�'WELL C NN°1U3�®1'ST 1RUZQ .to(t W t4.4 For InternalTTse Only: r;,, �°etFtY-rfjt�l: ;
1.Well ContractorEnffornmtion:
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Cenv.Th®mpg®n t , . •
1VaUCatmnetarName •
- - PROMTM. Desalt Ti'
441&&A • • t'Lb ft• t-,.,l m ^nsr . -IO Gptw -
NC WaaConCnaarCateeoti nN®Yer
Aqua®I�!!, lPIC. a• mour RIZCASDIG fat*> L METE:Deus)ORLDIERcef 'nmbte�:•_••:.••:.:,.••-
3�) •MORY TrD DLratsrso• 17 % h� •
Company Nome• i� 0 ft I v.b f Gas:- S�)1A�.1 p t.c. _
16.BONER CA3II S OR-TUBING fadothotoo
2.Welt Construction Permit : Dom. u dasedaaaa) -.
Ltstall oppllmbla troll eaonsrruettoapermics(La WC Coney,Stara VcNmiea eta.) e. "T�t s ngy7 rap
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3 Well Use(cheoicwefi use): ft. ft. to.
Water Supply Welk • 17 SCREEN:. :.
Agiiculiutal i ipeUPubi[e &SON' TO. DIAMETER A• - " .
8Lo3 SIZE TM. • Errr renv
Gealhennal e8tla fn.
(Ei g/Coolingsupply) Vie'-Amnia!
. lndustriaUCmnmercial
Residential Water Supply(shared) „lg.mow..
"Motion Mon ato 'nmaarzsrai' ': r
Dion-Water Supply Welly Eatsr.ae-ttisrtttertton.aAhnomvr"
lvrondarhig JQRecovety 0 t 2"0 ec.v e:„• e. t, +1;�f,.
Injection.Well: ft. ft.' !,,ty�c
AquiferRec OGroand►vaterRemgdiallen • •• a` f`
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19.•SANIGRAVEL PACKCirapptieabfo) . .•.. • , --
• golfer Stmageand Recovery OSal nrtyBarrier MOM To araTmum. , Emma imvemiann -
offer Test oStomvaterDtainage fr. p; . • 1
Experimental Technology rjSubsidenceControl ft fc
• Geothermal(Closed Loop) m r
'20.DRILLINGLOGIattich addttiaaelsheetsifne serA Geothermal(Beating/Cooling Return) f Other(explain under#21 Remarks) atom ft. "To R DFscRa�ttort(wTvr ra a,sommerrn�p�a�a •ras a e )
4.Date Well(s)Completed: —l'�'gel Well IDS CD ft .. S— • Dry 5 o:1
Sa.Well Locatlem: y
kituitct.co, (4
�!h!+ Sri ir&ft i'�,S"rtr rM t,o>!-e, 4--,r' t FaailitylOwaerNamo 'Facility MAIaopplicabto) le• fh � p�a a®
!ate— ��{ M Sw0, �+ trv�iv: t 'O® ft. r F, AiG
PhystadAddrese.Cay.tad.Tap '��®t COfn �, 5'?073
S O k�S 2L REMARKS ' 1 ,f .
County lr.r7ei^ri f' .^t. 5..
Pineal ldeahifieatiothNa0'tM DVtt'GI�rj+a
' Sit.Latitude and longitude in-degrtes/minutes/seconds or deebnal degrees:
Ctfwefl 8dd,one biking is sufficient) 22.Certification:
I —I 2'5
-Si of eiteloilConaottar Data
6.Is(are)the wddl(s ermanent orOImporery
Bysignlng this few,1 hereby e+ett(fjr deer the itch(s)was(area)centimexed la accordance
7.1s this a repair to au wasting well: Dyes or o with]HANCAC WC.01ODbr15ANCACt12C.0200 Wei I Coteaoactlen&anlortfsend theta
trait iaa repair.fill ets known mileaturraaloalnjomtauoaendespktrtheeateeoftre =?Pojt&lsreeataarbeeaprorldedlat&enrlleaner.rept&wafer el reetetlaaeetlea area the badcojtklsform.
23.Site diagram or:ddttiottel wdl details:1 '
. B.For Geoprobe/DFT or Closed-Loop Geothermal Wells having theme You may use the back of this page to provide additional well site details or well
construction.only LGW.1 is needed.Tdicate TOTAL NtiMBIItofwells• construction details. Yon may also attach additional pages ifnecessat)..
drilled: �:
SUB'YIITTAL INSTRUCTIONS .
9.Total well depth below load surface: - (�) 24a.For All Welts: Submit this fora within 30 days of completion of well
Formaleiplewellslfstalldeptl depths Willem,&rant:0e-3a 2Wand2Qi0n
/�t cartstruction'to the fo]lovrins i' .
10.Static water level below top of casing: (ft) Division of Water Resources.Information Processing tlait,
ljerarerknrllsabmecarin&uae"-" 161714fn0 Service Center,Raleigh,NC27699i617 •
• IL Borehole diameter: G. (In.) 24b.For'Wooden Wenn In addition to sending the form to the address in 24a
1Z Well construction method: y i✓ above.also submit one copy of this form within 30 days of completion of well
(Le ac�ymTaty,Ceble, tptesb.etc.) cattstructiontothefelW.ving ( i
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Rale,gh,NC276991636
-13a.Y held(gpm) t0 Method of test: Go h ) A�.�•-c— 24a.For Woe'Sanely&Injection Wells: In addition to sending the farm to
13b Disiofectioa t)ghe: �-� '� O� AmotmO ((o le.. the address(es)above also submit one copy)of this form within 30 days of
completion of well construction to the county,health department of the county
where constructed. L
FennGW--t Natal emeli=DeparemeetofEnvironmental Quality-Division of Water Romans Revised2-22.2016
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