GW1--05591_Well Construction - GW1_20230825

•
:. ,c 1'
• ' ' . , ' . 1\ . .-- - . Pri rm I'' I
WF]LLCONSTR UCTKOI`T MODR D�tC;7 Il) For Internal Use Only. :"
LWenContracterLdormation: jtntFO
1� r'ry
Cameron Bean 14.wnr®ezoa�s �� 1V.,-.a�
FROM 1D IITSCNa'[rON 4 -,
Welt c amactarNoase 1 QS $. R ?.s Ci '',..i.
451 8-A R. R i ,�f °x.•,tz.
NcwestC Cati5nfionxom6a tS.oUIERCAsi forrea easedeeu+)oBralea di -reialwAye �� :I ,
Aqua Dill,Inc. FROM to Dn xa-ratr sfficrarassr mATSlt1AL
• D f Art. is f'1�- -:,
Cmepmy it !(� 161N116R CASING ORTUBINGM� t"
(9 �t ,�x
SS MAMMAL
2.WellCoastraetioaPetatitti: FROM R ttr. ?` ,t
thrall applicable mUauttmrrtfon permits(Le.UIG Canny:Stela Vmiarrc4 eta)
8. >L im 1t
3.Well Use(ehackwell¢se): — � I• w
17 SCREEN � � I ii, '
j Water Supply WelleoM ro n �R ��s� MAfGwn
I ealbnal 0MunieipaRublic R R or 1 '
Geothetmal(Heating/CoolingSupply) Residential Water Supply(single) R R to
' dustnaICaamtetcial Reside tidal WaterSupply(shared) 1LGROUT
TD MAMMAL Fa1FLACP.bffi't�' OD&A(KODNr .'4
Norma-W ,
Supply Well: 'O R 3a S' , e.4c, 3 '
IRObr �
Monitoring �Recovc y ft. f 4
• Julien Went ft. ft.
ferRechmge QOmundwataRemediation 1g sAem,anAVELPAC liftwelizente) ' et
wirStorageandRecovery 0SalinityBarier FROM -TO MATERIAL 7IIaeLAc�7FN1t+ OD
fe
R ft.
.
Aquifer ®StmaatQDraioage
Expedmeufa1Teebnology DSabsideace Coated Geothermal(Closed Loop) O7racer 20.DRtrlstoWG WW1 adaxtoa tataetbxne v)
g Odter( laiaitnder#L1Remari�) FROM TO Dartorttema.beweu,mnnectetaa+a++a+� t
Geothermal(IleadngfCoola Realm) O R (fief ft• 4- d
4.DateWell(s)Completed: 81(ep.7 Weil 64 R /SS ` ,r !°t/{� r;.
R ft.Ba WdlLaeeUonr — 1
Y i-L� t,•�r a.
r.r�' �S AUG 2 5.20/3 ,
FaeilInsOweerN ise Pac3ay1DO(if sDpbeable)
.1-4(se to� I:tl(Cl'e weSr Tr ,, R ft. y rro+3 n'I.:a..sssaiay Ott'_ 3
Physlpl Addmss City,scamp C,21`7C
•
ASL`G 21.P.MIABSS
Cowdy • PmalIdeatifeadoallo.(Put) t'
5b,Latitude and lotgitudein doiem/mpmuterfsmondnp�ordedmal degrees: — 3t -
t 'Noy
�500s sir8iciaa)N D( �C 7 22.Certification: t
w 9 ;' ,
Q�T o SiguatuATMC ttifiedWellContractor Da�'I Qy,�� l '+
6' �)the wOII(s Parmanmt '— Bp afgefng thtejonn 1 hereby oettd that the well(s)ens(y}erc).canseuuad fa axwdanm !
tshh 15A NCAC 02C.0100 or15ANCAC 02C.0200 Well Coiobuctian Standards and that a
7.Is sarepairtoanexi existing Dyes or o mpyojthtsramdhasbemprdvtddtorhexrJimma ;
lfthfsisarrpap:/1Haatlamcmtveflca+nuaafonfyanrwt anAaplalnfhenahoaoJUre I. ,
If "imder fin:trawls section oron the beat gfVora. 23.Site diagram oraddttlonal welt details: i. Trl
Geothermal Wells the same You may use the back of this page to provide additional wen site details or well
S.For Geopronly1G or is needed.
t�sauctiea details.tourney also attach additionalpagesifn
eaasttuction,oaiYIGW-lisneeGed Indicate TOTAL NUMBER ofwalls SUBX101TMINETRUCTXONS �� ,
drilled: 1 S 5 - ' .
my surface (�) ?Aa far All Webs: Submit this fog wiiltin 30 days of completion of well
9 Total well ISe 1 t fed 00'and2@l00) construction to the "`
FormortipleweRsUstandeprhs jt0jjerae(aarmp - C� -
10.Stade water level below top of adage st
y� (ft.) Division of Water Resources,Informotion Fracas,sing Unit,
Master reseris above assia%use+" 1617 Mall Service C.enter,Roldglr,1tC276991617
11.Boreboladiameter% Q/ Cam) i4t.For Infection Welly: In addition to sending the fora to the
above,also submit sae copy of this form within 30 addt ass in24a
method; r?krN cuastrnctiantothefollowing �; days of�rnpletioaof welt
(i.e.auger, �'etc.) II r Divialon of WaterReso� Unaetg[ound ,
FOR WATER SUPPLY WELLS ONLY: 1636ManServicaCea ,Rat ltgeedonCoatrotPrograin,
.NC 27699-1636
C 24o Fotr Water SnoDly&ixiccb;on Weitg; °
O Method of test: l•t� � 1
13e.Yfela(gpm) tt� // the addresses)above,also bvbmit one c tn.aaditionto s
i� -l4• Atnennt: Giv Fi�Z.- campletioa of wall oonstructioa to the of ItLis_fostn witiim 30 of
13b.Dlstnfedion type: t where mistrusted. tY•healHt
�P lent of.tbo county
nts
FaanGW-1 t' worthonus DepaAmeatefEnvimnmeatal Quality-Division ofWaleramou
} Revi 2.22-ZQ16
_ <_.