GW1--05883_Well Construction - GW1_20230918

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�p�,� lfrifit 6'otm
"° nneua:i:iiik` (C®'".in(GW-]i4 For Internal Use Only. i .
• I1.Well Contuns for lntortnatioa:
Cameron Bazin • 14.WATERZONES
FROM TO DESCRIPTION.. I
WO ContractorNemo Stg< IL R. Zo ^ 7
• 4518-A 1 n. IL (TltY,,
NC Well ContxactorCesdficalionNumber is.OUTER CASING(for multi-eased wells)OR LINER(E it limble)
Aqua Drill,Inc. FROM TO DIAMETER + TRIMNESS MATE/AL
_s �y ID B' iOS ft Cp iw � —
CompName
t 16.INNER CASING OR TUBING(Qeathermnldesed-loop)
2.Well Construction Permit At `. f 1�Y FROM TO DIAMETER , TRIMNESS MATERIAL I
. List al appllcebfe mil cue RREEongemurs(r a UIC,CeW State:Variance.eta) -It. R.
3.Well Use(cbeckwell use): ft. ft In.
Water Supply Well: 17.SCREEN
. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ,
''cultural OMmicipal/Public ft. R. In.
I!Geothermal(Heating/Cooling Supply) ;y`esidential Water Supply(single) it. ft. Ia
Industrial/Commercial *Residential Water Supply(shared)
ID.
- �lrri On _ FROM
ODTO • MATERIAL EMPLACEMENT METIROD&AMOUNT
Nor-Water Supply Well: it 2, tt. 4 45'
It Monitoring f Recovcry ft. ft.
Injection Well: •
*Aquifer Recharge °GroundwaterRemediation a.
StorageNI19.SAND/GRAVEL PACK Of applicable)
and Recovery �SaliniiyRanier FROM .TO MATERIAL EMPL.ACEMENTMETROD
+Aquifer Test OstoseramerDtaioage iL ft. 1
•Experimental Technology OSubsidenceControl • ft. fr. ,
illi Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach addGUoeol s is if nrsi Er°)
VI Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM . TO _DESCRIPTION(color,ttmanev.wut.«xtvice ets dell
O ft* I th 1 ;
4.Date Wallis)Completed: 9//z 5 WellMit `to R' Sv5 nc..
Se.Well l ocelion: q ft'. IL 1 •
alk
Faclity/Owners Name Fac1htyIDA(if opplicalile) ' IL IL t._t„,"f.,.•I. \' 5....... ,...s.
�,-r��.vi�,. 0( . P sv� �` R. e D I B 2023
PbydegAdotessicity aa0.4 tr. tL p •
.i_7( e 21.REMARKS ...........c:..� Pfr-" (
-0 UII
COaaty Parcel IdemlficationNo.(PIN) ixVJvj a
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5b.Latitude and/ongibide in degrees/nrinuteslseconde or decimal degrees: .
.Orwell fie%cne'lat/lang is eofficiat) 22.Certif'Tcation:
3 6,37.95- N e, 35 c2 c, w i
Signnwo a cects�traesor' D / - 2
6.1s(are)the well(s) Permuneut or Temporary r this arm.I
By signing Ihereby age that Oa we (r)um(suers)coresduaed in aarardanoe
7.Jr,tins a repair to on c de:og cven: jai Yes or "7o with 154 NCAC 02C.0100 or ISANCAC'B2C.020019eit Cans:motion Standards and that a
Ifihisrsa►epaB;fi l and yawn well canstrua on Info:maY eaglarit the narme(like eopyoJthta record hue 42enProw1dediOlhOWollawner,
wok wider P21 remarks section.oron thebackofrldejann 23.Site diagram or addlttonal well details:
Yon may use'the back of thito.
S.For ipaohal a or®osed A.aap Geothermal Welts having the same page'tm,progide additional well site details or well
' can
onlyl rGW-lisneeded Indicate TOTA?;NiIMBERofwells constructiondetails.Youmayalsoattachadditionalpagesifnecessary.
straetion,
drilled:- //�+ sUslVIIT 411.IQN UC1TQNS
�alew taTtd sotface% �0 7 (ft) 24a.For All Wells: Submit this{fog within 30 days 9 1.°61 w4 depfih ,. , construction to rise following: of completion of well
Parmultlgletvillslrsttstt l ( plc-3e2_,an ,@I 0)
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(ft) Division of Water Reaou I' Ynformiition ProcessiD
10.Btr�tfe water level lieYe0 faPoicasing: 1637 Mail Servlce i.dal g Orlin
- ftvatarWellsirbavasasiag; etgh,NC27G991G1T
CIO
go.ForJntection Welts: In addition to sending the fang to the ad
U.Borehole tiErsmEtea% - above,also submit one copy of this lorm within 30 days.of dress 1a 24a
12.'Well �ellag*gad:
r° / cm:Sanctionto the followin 1completion of well
(i.e.auge<,IOfS3Y cams,daeettneb,°L) Division' of Water
SU � °°d b)ection Cotrfl1G35taQary C 1Dteie6,NC Z769gm63o Pr
a
- ONLY:
SUP
✓q4 r
24c.For Water Small/8c3alectiont Wells:
�(etttad diva: In mddititm to sending the fnrm to
13p.Meld(gniD /� the address(es) above, also submit,bar,con
(� Atha nt" le 1 colnpletios ru well construction to .''O cotmtY eal "ithin3�da
Yo thisf
whtao constructed. h �Pa a county
Y31F.gDisillfeeC on tall?: j
worth
CamliaaDepaltmeotofEnvuonme Ind Quality-Division ofWaterR
RIM 66V--1 Rtv!sed 2 23 2016.
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