GW1--02906_Well Construction - GW1_20240510

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val�lVa�¢;�1vS'I RUsC'Y ON RECORD(G'lhl-1) .
•For Internal Use Only:
Chas Kin9 ._ . i•1.Well Contractor Information . i• .: . .
• Well Contrector Nome :•.- •
��ATER'2�IVF8• I
PTIO
2oeaA %a T 4 l g : .57 x
NC Well GomtactorCeniticotton'Ntunb•ct - .
• ' :: •Aqua.Drill,lnc. .+.. • � . ' • .. • . ING(tor.mnitt�eatW wells}OR'LtIYERN'ab 1tea61e). .':• • � �.
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FRO. TO R `.I.TUtQLNES5
• 2.Well Constructton•Permitii '• • �5 • . NERtherm dICKNESp
Lst•all oppllcuGle urll eonirnrcylan pennitr(l e: !4 Co:nrn•Srtue.•Variance err..) �. R.
6 I CASING OR TUBING(Qeo
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3:�WeB Ude(check well • .
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• Witter$p1PP�1'Well .. , _
- . ater:40 Spits/.:. • '' : • • • • • • 17 S i E To•.
QM� PaWPubli¢ • •,.. ::: Iii SLOT SIZE :':,••THICKNESS • :tHAT•.• ••.
Gcothen nl.(Heatia Coohn Su 1 R. iw
: 8i 8 PP y)'. Ra4idcntinl irptCr Supply(single)
':. lndustrwUConmlcrcicl' -• DRcsidential Water Supply(shared) : . -
liiigatioa•: ..., : '... . '.• . ',.. . • � � : �. . IlR.GROUT _ •
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TO N4iTRRiAL: EMPLACEMENTM6THOD-0AMOUMr
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Monitoring. : . : • • . B nfn i $4►v1
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Aquifer Recharge • • DGmundwater
. Athufer Stortigc and ••2: Rem -
ediation B'
9 QSnlinityBarrier 19 SDt /GRAVBLPAQCptepp>tea6le)
Ter Sri t • • FROM .. TO;• Fa1PLAC8�1&►T.MP.TROD. . . DStonnwnterlhgmagC • . .ft • ii .MATERIAL". :- ,
Experimental Technology ' QSubsidence Control • • .
Geothcnrinl.(Ciescd Loop). .:. • . . .' B :. • • • • • � • .
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.. - - ... . 20 DRILLING -
` Geothcmiul.(Heating/Cooling Retum). ' l}Other(explain undel'd21.Remarks) OAr': T (.. t�1'1� ror nentn�mt1,1711 ,
tfesb nddifional ..-
• 'Dttscal tuate tizzy etc.)..
4 Date•Wells)Completed 317 .ZY.Wei iD#-
Sa..Well Location:. .
- :35'
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F::..• :- :... dame '
.'• • • Fac7itylDtd(ifapplicabio)`. R
PlyrstnilAddnuerCity pndZiP • +�f/1(n/ j1f�tG
G(l, 21.REMARKS !1�}
Pamel ldentitipecn'Vo:(PIM 2 U L`t-
.56.latitude and longitude in de 2'.-jfminuees/seconds or declare/degrees, i:lf:v ..�.: ,� a-,;y;=.:1 t
of ull Held,oneHV1ong R sofftcicatj :. :
22.'Ccrtltlt8ti01t' a r,c^c:LJt•�. ' . .
6.Ia(sre)tnc we s
=3• ••.ii(l�ermancat: or,QTcmporal� Sigtmturo ofCScniticd Well tbnav
" . ' . � .�' .. .: '•' .; : ' '.�. . - ''Data:' :. .
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1e t.. a Ye,'i£:7 to an eulslingtve!!d . Oyes, or ,V°. • •• • B,i�slgnlrtg.dife fnr'rnr 1/iereh;rcrtg./len hh:nrll(s)iris(Ilene/'rrriceirur te,J In anlonelaair
(fh/s.ls g r pah;fll onikna:m uir//1Vicirtrtitan h,fo ntmlan and rr.plaffn Or danrrr yr/ie "�/n j hlc rivord oq iwen pmt*gd m the till a4 NCAC 02C wmci:,; •Chu/rrrrHori Sla- ''-• and that a
trpalr unrler 421:iyinta rsct llae or on the hark ofINafnnn: . . • ' • n
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A.For Gco robc/DPT of Closed-Lao•Gcotb. .. „ Wc'.h. . rho some • 23 Site d iagram or a diti•on well detta0s : •
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constnlctiO..only 1 OW-I is heeded; Indicate TOTA1;Iv.L;y13ER of wells" also tO P vldi additions)i►r@11 site details of well drilled: conshuetioa details. You may also atteah addtttonalitages ifhecessary.
9.Tot �ccR depth below lend surface �d,� •
SUB,Vi11TA_r,1Lh�'rortrrrni►fc.
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Fnrnahtdi/e+rdepthbeowl ifdfsuffacern le-3tra'70 a»il'- . (ft) •- .a�lot79 24o For:All ells: Submit this form within 30 days,of completion of wall
10.Starit:�obter level belotv,top of •'constnlction to ho•follomng; �
casing• .C�(�
10f Sta a w•a er•le is bel ass•//+- ' . (�). Division of Water Resources,information Processing Unit,.
1 I ]Borehole dtametere ": (O •
1617 Map$ ce Center;Raleigh,
246.For i tttoh Wells; 1n
1;..it cii.eonstruction method:• / : .• .s6ov..c,•also submit ona Copy. oafddlttwn�t
NC;76991617
Ii c co rc to .•! 1"Z,l�,..- •• . ....
gee wry: ablw direct p,, ctc.l •construction to the follow3
J osea sending Ute form to the address in 24a.
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form within. 0 goys of oiimplclioa cif well .•
..FOR Wit''lit SUPPLY WELLS O\'LYb; • • • •
adcrgto ti D"Control Progra
13a. ?ei:1 m •
a o 163.6.Ma11 Se1C enter, al t NC 37699-1636 •
Dlvlsio
ethod of•lest•S .. .24c.Bar Water Sunni &iaieetion•iVdls: In addition to.
13b.H)$t: •cc' • ;ype; •
Amottah dress( ) above, also ubnut ono copy of this formswi h ng30odayss o
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e ad � to.
completion ofwe construction.to the county health department of the county
. . Form fa-1
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No Th('u°iina Department Of Envii nmental QiidGty=Dirisiori drifter Resources I