GW1--04117_Well Construction - GW1_20240712

LL CONSTRUCTION RECORD(rW 11
For Internal Use Only: Print Form
I.Well Contractor Information:
—.
David L. Hard , Jr.
WelllCo Nam: 14.WA Zp _.
290fi-A PROM ,O DESCR
Milanili
NC Well Contractor Ce°iScetioa Number
Aqua Drill, Inc. l�ovr�Rcns©„� , ,,
is. 7O oltt ., ,, a,.,„.,„.
Cemp3°y Nme D A• r�
IIMMIKRAW
L Well Construction Permit a: z � l 16.INNER©•�G (her �i7/��-�
List all applicable well construction permits(Gem Coup FROM DIAMETER
ry.Smte,Yorianrx ac) �� MA
3.Well Use(check well use): 111111121111111111 1°
Water Supply Well: in
Agricultural17.`N' .:4 -_
0Munien al � ® ally(iy. MATERIAL
�Geothermal(Heating/Cooling Supply) °Resfdentiel Water Supply �
•Industrial/Commercial PPY ed
if ®IResideatial Water Supply(shared) © Mili
'Nile;on
IL • s UT
ll _.
Non•Water Supply Well: .. 'ro >titATgnt�,
�� n earn
11 Monitoring I Recovery1111121111111113
® �i 7t
injection Well:
II Aquifer Recharge °Groundwater Remediation
M.Aquifer Storage and Recovery ly
�Salini Barrier SANDiGRAVELPACK tY tfa,
AquiferTesi PROM
atAr�ru _ EMPLACEMENT
OStormwaterI?rafnagQ — IDETHoO
"[Experimental Technology 0Subsidenee Comrol
j,Geothermal(Closed Loop) fr • ft.
Tracer
j. Geothermal(Hearing/coolittg Return) 20•DR1LLDIG LOG attach additional. _•s 1 ..
1111 Other(ex.lain under el Remarks 1127'' TO / :_:. •,u__.ews,oet, ,._..,_ a
4.Date Well(s) ell B)a Completed: 7 it F itW
Sa.Well Location: ""- err•E 47 ri `l3�stt'
Faerlity/OwturNnme
Foorlity MO 0/applicable)
a
ial Address.City Zip / F: z /Q3 R R• ray
•
TPJ�I'✓4 /7 21.REMARKS irk L 1 2 Zn)
County
Parcel Identification Na(PIN) n..,y
5b.Latitude and longitude la degrees/Minutes/se conds or decimal degrees: �"4 Orwell field,one letfloeg is suf6eienD ,
,Ih r� '� �ff lv 22. a:4!i'.- lion: C—( /�/t`7f t P� o,..�a,t,k,
W , ce .
6.Is(are)the wcn(s) Permananr or t'd
QlTemporary Si.Sit..n... ofCertikedWellC / Data /214 c
7.is Ibis a repair to an existing well: ®Yes or Sy Signing this farm,I hereby c that the will(s)saner(were)cov>mnatedln accordance
If this is a repair,fill out known well construction in)ynnarton No f with ISof hC C QIC i 15ANCAC 01C.O20t1(Yell Construction StamfoMr and ghat a
repair under all remarks section or on the bath of thlsfornt. aplo/n the mane oldie
copy of this record Ilse bean provided to die well4rwner.
S.For Geoprobe/DPT or Closed-LoopGeothermal 23.Site diagram or additional well detail;:
construction,only1 GW thermal Wells having the same
You may use the back of this page to provide additional well site details or well
n. 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if nerresary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
days
Formdnplewellsltsralldepthsifdiiferent(example-3@200'aaligilqtY•?f
(�) fie' For MI Wells: Submit this form within 30
construction to the following: of completion of well
10.Static water level below top of casing: C "/) (IL)
Ifwnterlevel is above casing rise,•+•• C C Division of Water Rae s,iuf Raleigh,
Processing Unit,
6/
1617 Mary Service Center,Raleigh,NC 27690-1617
11.Borehole diameter: 00
An / 246.For Inlection Wells: In addition to rending the form to the address in 24a
1L Well construction method: /7/, Ale fee above,also submit one copy of this foam within 30 days of completion of well
(ia auger,rotary,cable,direct posh.me,) construction to the following:
FOR WATER SUPPLY WELLS O Y: Division of Water Resources,Underground Injection Control Program,
13a.Yield(Rpm) �/ 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: d 24e For Water SuaatyIpieciion Weil In addition to sending the form to
'�Dfsinfeetlon �� /m • tits address(es) above, also submit one copy of this form within 30 days of
/Q4onat: completion of well construction to the county health department of the county
where constructed.
t North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016