GW1--03638_Well Construction - GW1_20240618

"1EY.L ®AT3 g`Td�7CT_______Kt�
Print Form
F er interned Use Oniyo
I.Well Contractor Information;
David Belcher
84.WATER ZONES
'Won ControctoTNemo _ FROM TO aEfiCRIP6r®�
4594A ` 3cOn° �) t �� i-Yt- r)
NC Wen Contractor CertifieationNum oe t�?f';"}� y 0' INN rn .I1'PIl'-fit ire')
Aqua Drill,inc. is ts. etCnsimp formal eawa'.lea Nee tleetsrep
RIAL
Company Nemo _� , a 6t. �- e' SDIrr�( �
irr, s1� Gi .,,n ,o z.Well CaatuucNm®teraniC#: 21 Z„ 71 Y 2 niaa x
90 g@
LIs , BP. .
t all applicable well carrstrucriarr permits(l.e.UIC,Oiw t/arlmsr
Mate. a,OW
30 Weil BJee(cheek well use): ` ---i:1--....-- ft. - ht.
Water Supply W a 1-v3 N —
Ayticulturaiarnn ays mdAMesEn WAIT MU THICKNESS aaArsaeAt.
rcrpaUPmblic tt Ht. §a.
I;Geothermal Meeting/Cooling Supply) Elli.fResidential Water Supply(single) - -• •
t ittduatriel/Cmmmercial 0° ft. MU
Ditesrdcntial Water Supply(altered) Pa.Gnavr
M 11f1Y tier{ ,...MI__ _ 41@ � MATERIAL _` EMPLACEMENT METHOD&AMOUIer
Non-Water Supply Well:
*Monitoring Ili+lte�mvery $ �c5 ,-R} i r6 fir if Cilps-� Nyr•)r:e
IAquifer Recharge ;It Groundwater itemedierion Gam
flid Aquifer Storage and Recovery ;Utz Salinity Barrier rIL I<ACE ° !_
:11'Aquifer Test ill) EMPLACEMENIWIL'da�
,Storrnwater Drainage a. i
i�E perimental Technology °Subsidence Control ft. i _
Geothermal(Closed Loop) oTrace7 2e
AGeothemnai(Reating/Cooliag Return) E;,ether(cxplain under#9l Eilomatka) rt - , S4oe+r��►�
4.Date Walks)Com(tleted: S : � Weil ' # ------- ) a' (CADIL �_C S'a. S
Sa.Weil London: 610 d 77 m 1 S, Sat
/3(i4han l.e/v•`arc). 77 �� Liie f.
PaaifigdOwaallaoe Fanny Mg(ifappliceble) s / '��
r r- -tt. �. •`�
'"ha-•-�.City,an Zip , O. l i!NI I g ZUZ4
Sus c.(' �3 >a>a t
County ?�- n IA Parcel ddendReation No.(PIN) y
Ste.]Latitude and Maude ha reeska acres/ers©n
(if well field,oes Won is un or aortal degrees::
irlfa ielle m u'��a
Q'j 3tgnatnreo C Ged�I/ell Contractor Ds*
Z.la(a& `�eatllf� (� Ny alpine!his Egret,1 hereby eta? y Mai 21 se svell(s)was(were)conaattald is amehmea
8 DIM S7 '' IVZ wirn ISA NCAC 02C.0100 or ISAN'CACN'C.0200 Well Consnvulonna avisall/Meta
MSra illyailUMaltiallailWUconrtruetlonIsfor zainnandexplaintheharmalike copy sf Mir,ewa;ndham been provided tatlieruehrowxer.
reiral'arior ill mod craft anon thebarkafthirform..
El SW Own cif asdlti139curaN via Palle Rai he.
L>rar Otoordedirt or mop GeotherasaG Wei:o having the seine 'nu swum the basis of this page to peovide additional well site details or well
eaaehnettokl,only 1MN is goaded. nndicate TOTAL WilVl®Rl2 Owens Pao reto ied'sE ats. You:may also anal additional pages''necessary.
ailldr
ToI:itta>i dill Mid led delheas
� imti }�I �tAolatpJa9(a)zOfl' min ®' con.per AA lsbo�t Submit ibis feria within 30 days of uormpletion of well
lrulderisest Is dasasuiss am No'
aNide did kid law bpif auk. 30 ,_,.,.,bond.) Dletresetlider>inppq,l
15171Adl deniesC Mr,adlly>MC ,i !'�
Mira Tom ryikd .11 MA :: to additions to min 111a Ida to es aim k 24a
Po.. amulkarr aae�da�-j��► fir,/ Ar-- anima also submit one copy of this tuna with 3O ire of: a[well•
S n1146 silt,iatg<rR,eta) ''"" eortesrasceion to the following:
r>6<MWA�SUPPLY eNtiv1•a� c — ��� fID15er,1Blaara m>t Wenter L�assourrces,tt>and®rlllarotladlldaellao t7ooltatl4a
ICA Heil Service Cstatsr,ha liNaleffell i0d
MI6 Matad m4 yes3;- TA , 24e.bliktaappotitAtilialLoins Waft Is addition to sending bit*lo
)� 7O�'i. to address(es)above, also submit one copy of ibis form within 30 days of
iL — �aa®tt_-.,_i(0.c7 . _ , completion of well construction to the county;iealth department of the county
- --�- --...____m__s where nonstnicted.