GW1--00162_Well Construction - GW1_20231229

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Print Farm
WELL CONSTRUCUOl� CO =ll For Internal Use Only:
1.Well Contractor Information:
David Belcher 24.WATER EOM I
WallContmotorNemo ------- MOM Ws DESCRiPTION
4594-A 490 fa Ls4 Its Cw9idl C c ir.-0
ft. ft.
NC Well Cowman.Certification Number 2s.OUTINCCASING(for maltkasedwelle)OR LINER(if tt Heath)
Aqua Drill,Inc. MOM te DIA6unrun , Twci n Ss MATERIAL
Company Name t ft. So e. Via.a5 12' .Si WQi Air
If.INNERCASINGORTUBINGfuoteeenieI tteddeen)
q
2.Well Construction Permit#: A VT?V FROM iO DIANETER TE[CKS ESS MATERIAL
List all eppllcable well constructionperm&Ev(i.2.UIC,Coup%State,Vaitaiwa etc) it. ft. 'ht.
3.WeU•U6e(eheskwell use); • ft. ft. i.in. ,
Water SupplyWe l: - .
17.SCREEN ,
Aglicaltaral :+Rohl TO DIAMETER SLOT SIZE THICKNESS b4ATt:RIAL
' icipal/Public • it. •ft. in.
Geothermal(Heating(CoolingSupply) alit,Residential Water Supply(single) ft. ft. M.
Industrial/Commercial DResidential Water Supply(shared) Itt.Glow
Irrigation FROM TO MATERIAL EMPLACOMENTMErEOD&AMOUNT
Non-Water Supply Well: ®^ a it' 0 ft. %of oriao, ''i�t.:6'C'M •e, 4 I-VA
Monitoring • , DRecovery ft. it . I {J
action Went •
ft. ft
AquitbrRecharge 'jai?GreundwaterRemediation
•Aquifer Stepage and Recovery ;1i Sehinhty Barrier 13 SAMB RAe1ELPACEc(lfapnikabte)
FROM TO MA4ERiAL • EMPLACEMENT MEMO
golfer Test DStannweter Drainage ft. ft. j'
Experimental Technology °ISubsidence Control • ft. ft. I ' -
Geothermal(Closed Loop) Dimcer - :ill MOW. NO LOG fettae eddltfoaal*ash Er moss sry)
• Geothermal aleatinpJCooliagRetem) fOther(explainander021Remarks� FROM To LutscalwnoN/corm:I.raaeu:.mumextrne,mct■.tze.otal
© ft° ..,� ft. t ) Sn'A . . . . . ..
4.Date Wdl(P)Completed: ►, •i 5•g Well TN Ga -fL g ) . ft' 'Ric( Cil^i-r,;
Se.Well Locations no /:.. l3C j ft. eh tt P. eirle(l'aI' , •
FaoilltylOamarNeme FacaityIDN(ifapplloeble) ft. . fr. • j .
lOGy CGtip ss r•l d( )1 �/341):I: 1 i IC761fo .fr. JF 1. LLJ J
•
PhysicalAddrots,City,and Zip 7' rt. ft.
County Pared Identification No.pin)
SON Lathe::and•ugitud®In degrees/1, pu es/aeconds or de:A=1.adega am
(ffwell field,one Lu/ionr,Is caac eat) 23.Ceatifleathan: li
A60 p 7 g51.7" it ci'Oa 1Lf 40.4'• w
.
6.Is(are)to wel➢(s) ernlaneat or DTelnporary Signature ofCeetitied Weil Contactor i Date
By signetg this bin,I hereby certi/y that's t wanes)wav(were)'constructed In accordance
7 Is this a repair to an exlatingwell: Oyes or ; iNo with ISA NCAC 02C.0I0D.or ISANCAC 02C.0200 GYell Conslucicn*Wards gad drat a
eta is a reSahlfill out ham well construction itiformadan and explain Silo nature oftim copy ofthis m eAlhas hew Prodded toile well owner.
repair under#2l nomads section arms the bark ofthlsfbrm• 23.Site Iliageana or additional well details:
8.Nor'copr PT or Closed-Loop Geothermal Wells having the same You tray use the back of this page to provide additional well site details or well
construction,only 1 GW l is:leaded. rodiostte TOTAL NUMBER of wells construction details. You may alto attach additional pages if:iecnsa y.
armed
n710garaB.1)ielfi�'�ItHJ2"Il'ig .
O.To, well depth➢oelots fella surface: Rt7.i (ft) 24e. el i All Wells: Submit this fornl within 30 days of completion of well
Formultiple wail Ilstefldepths(/'diferent(manpl&WOO'emd2Q10D) i
colistrnctiontathefollowingt i, I
30.Static water level beI®wtopofeasing: Lib (ft) Diviis➢es of Water Resources,lntbrmation Process!,;.Unit,
lfwaler level lealto°nateuse"+"
1:19 Hall Service Centeno Raleigh,NC 276994617 •
Ill.Rorekole diameter: t"c+ a
81t.yap lgdcfiao W fiat In addition to sending the form to the address in 24a
i�e",c� A above,also submit one copy of this form within•30 days of completion of welt•
12.Well wrms@Pttstlon methods ie}'�
(L+.anger,rotagr,cable,directpeal etc.) �f censfructionto the fallowing: I; •
�1t WAWA®DisB'L9I 9WELLl1®FIbYf o,.vlsion offWt etc&Euro%Ural•• aoudd Injection Control B agra%
16536 kfal@Service Calm�,Raleigh,NC 37699.1636
13e.llield(gpm) Re) Method deem_ ,tld•i'1`ll "Tlry►P.. mg,yew Wntiy Ili ja euttotq� ,�t11V is t In addition to sending the farm to
131C.IDislufectloD$+Lle: fli 7i�.�l���c7 the addresses)above, alai submit One copy of this than within 30 days of
Amount: " Ike t?:. . completion of well construction to the county health department'of the county
where COnat noted. •
FourOW-1 w,s..,...v..— _ate'-- ._.... .., ' — ----