GW1-2022-05592_Well Construction - GW1_20220614

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1.Well Contractor Information:
Reuben W. C12yt©n, 1H 14.WATEP ZONES
Well Contractor Name FROM TO I DESCMTION
2241=A 00 fc. fir. -11r1*94
'rf
NC Well Contractor CertificationNumbcr 165 ft. 170 fit. I
Drill,
IS.OUTER CASINO for T! tB-tased weds OR LAVER i a iicable)
DD-fi Aqua Bl9, Inc. FRORY I TO 111MME:ER TAICa7YE5� aL1T1721AL
a UC
Company Name
16.INNER CASINC OR TURING(geotbermai closed-loo )
2.Weil Construction Permit#: -3014 FRORt TO DYtu'tTE=R' THICEMSS RtATEnTAL
LLct all anpllcable well mustntctinn pertxilr(i.e U1C,Camrry.State,rrarlm7c4 etc.) fit. fit. in,
3.Well Use(check well use): fit. ft. in.
Water Supply Well.- 17.SCREEN
MAI TO I DIAMEM ,SLOTSIM. I THfr9N•ESS RtATEP.IAL
Agricultural 1 unicipal/Public fit. fL in•
Geothermal(Heating/CDoling Supply) Residential Water Supply(single) ft. f'. io
lndustriaKommercial OResidential Water Supply(shared) 19 GROUT
iltrigation FROM TO RTATERIAL DIFLACERTENTRIETROD&ARTOWNr
Non-Water Supply Well: 0
f0 i ft.
iitrionitorin.- DRecovery fit. fir.
Injection Welt:
fit. fit.
__ IAquiferRecharge DGroundtvaterRemediation
19.SArqD/GRAVELPACIC(ifnamlimbleI
(Aquifer Storage and Recovery Salinity Barier FROttt 'to MATERIAL ENTPLACEMENTRICMOD
PAquifer Test ft,g ft.
—Experimental Technology OSubsidence Control ft. ft.
(Geothermal(Closed Loop) OTracer 29.DRILLING LOG(attach additianni*beets icnecessan.
Geothermal(HeatinglCooling Return) 00ther(explain under#21 Remarks) FR01" TO DESCRIPTION(color.bardarsr son/mck t e.ernin size,ct�
fto t. , tt. n
acp
4.Date WellI(s)Completed:� 3 a a"ll-Dm 1 ft. ft. I ,
Sa.F.°Jell Location: ft. ft. }
�To co �7i xat
Facility/Otw(r Name Facility ID."(if applicable) C1a ft. pit C-co2n,'-Pe
fF•
sv�• �c�4 Q,t) Gin - ? fit: rr
r2 ltl•� �f4s)�';.
Physical Address,City,and Zip fit. ft.
,nV)e-S 21.REMARKS
County Parcel Identification No.(PIN) 2
s-b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if tsell fiend.one lat/long is sufficient) /r� 22.Certification: 1 �
o / 1
�sl ,qtl 1�i 4L ��r 34.9 've !n`�'� � RRVut-Win
fir.ls(nre)the tioetl(s)- Permanent or Di T emporarav Signature of Certified Well Contractor Datc
Ay sig»i»g this fora),i hereby terrify that the well(s)was(were)constructed in accordmrce
7.Is this a repair to an eSisting tVelk n i es or zwo with ISA r1'C.4C 02C.0100 or ISA A'CAC 02C.0200 11e11 Cm).structimi Standard.*a»d that a
ifthcs is a repair•fill ma known well construction it formation and explain the nanrrd rfthe Conn of this rucard has heel)provided in the well rnpoer.
repair rarder Ql retaarkv section or air fine haclr of thisfirin.
23.Site diagram or additional iveil''details:
8.For Geopt obeADPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-i is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SfllBM! ErIL INI ISTRUC' SONS
9.Total well depth below land surface: oZ4; (fL) 24a, For All �°Jells: Submit this form within 30 days of completion of well
hnrn)7r/riple wells list all depths ifdilferear(era a e-3@200'and 2@10U') construction to the following
10.Static water level below top of casing: (fit.) Division of Waicr Resources,Information Processing 1)nit, .
If aarer level is abm a casir+g,use"+" 1617 INWI Service Center,Raleigh,PVC 276994617
It.Borehole diameter: (in.) 24b.For iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well.
12.Weil construction method:-AV_ rco u C construction to.the following:
(i.e.auger,rotary,cable,direct plush,etc.) 01
Division of Water(Resources,Underground Injection Control Program
FOR WATER SUPPLY'WELLS ONLY: 1636)Mail Service Center,Raleigh,NC 27699-1636 a
13a.Yield(gpm) �� M,ethod of test: �Ql-Ttrn 24c.For®dater Supple,&dnaection Wells: In addition to sending the form to
C the address(es) above, also submit one copy of this foot within 30 days of
13b.Disinfection types HTI 7AO %O Amount: &pz completion of well construction to 3 the county health department of the county
where constructed.
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Pori GW-1 North Carolina Department of Envimnmental Quality-Division of Water Resources Revised 2 7--2016