GW1-2022-06064_Well Construction - GW1_20220629

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1 ,Name 4.WATCR ZONES
B-A cxont Totz"r nPscR>pTion ii
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tar at�frcationNumber ft. ft. !j
Aqua Drill, Inc. 1.7.QOTERCASIPIG formolticwedzveLls RtOM ORLII�R(If n liable !p
TO Name DIAMETER TLUU&NESS TERIAL -t i CompanS' ft, ft f
�o Ire. AR ;
2•WeB Constructials Permit 9 W 16.INNER CASING ORTUBING 1 otttermal closed-loop)
'List all FROM TO DteMc^rsv
3-Well Use(check well
TFIICKNFBS MATERW,
i QoP/fable x�Ij cons t ructforr pPrnrUS(I.I UIC,Coup State,Irarionce,etcJ fi:
ft. in.
R use):
WIster Supply ft• ft in.
PP Y R ell: M SCREEN
nAg-Mural FROM TO DIAMETER 5LOTSf7E Ta1CKNES,S
GeotheTTal nMunlmpallPuh)ic ft in.
(HeatiTTg(Cooling Supply) MATERI IL
ft Residential Water Supply(single)
i Iudustrial/Com.e1tiyal ft. ft LL
Residential Water Supply(shared)
- Lion I&GROUT
1r10&--Water FROM TO MATERIAL EMPLACEMENt.MMIOD&AMOUNT
Supply WeIl: ft tt S Monitoring Recovery
In]ecflon Well: ft ft
Aquifer Recharge ft. ft
Groundwater Renmediation
Aquifer Storage and Recovery Salmi Bauier 19.SAND/GRAVEL PACK tfa limbfe
RAquiferTest
PROAf TO MATERLAL ENipLACEMMiTMETHOD OStunnwaterDrainaae It R
Experimental Technology OSnbsidence Control ft ft
Geotheanal(Close3 Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geotht mint(AeatingJCaoling Return) _)Other(explain under#2I Remarks) FROM TO DESCRIPTION color,hardness,solVrack . s,zz,cM
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4.hate Wells)Completed: t 5 Z 1-wal ID# ft' ft �Ta1i1�•
Sa.TJ a Location: fL a
rf"'A y4 ft. ft
Facility/Owner Nam Facility ID#(ifapplicable) ft ft
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Physical Address,City,and Zip ft
21.REMARKS
County ParceIIdentificationNo.(PIN)
5h.Latitude and longitude in degrees/minnbes/seconds or decimal degrees:
(ifwcll field,one lar/longis sufficieut) 22.Certification:
t.� e
i SigoatmeofCaffed Well Conhaetor Date I
the well s eat or Temporary
By signing This form,I herelry certtJ•that the 1se11(s)was(were)constructed in accordance
well: �{yeq QT No wfth 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Melt Construction Standards and that a
i 7.1•S tjli5 a rCpeppjr•to an CyaSting NJ copy of this record has been provided to the imll owner-
JrhIS IS Q.�Jtr!•u aidlntown well construction iftformallo and eTIa die nature ajthe
r �#2L remoras section or an the back ofdris form 23.Site diagram or additional well details:
repay You may use the back of this page to provide additional well site details or well
8. thermal Wells having the same construction details. You may also attach additional pages ifnecessary.
For t,eoprobelDl'7 or Closed-LOOP Geo
l TOTAL NUMBER oEwells
c�stn�on,only 1 GW-1 is needed. Indicate SUBMrrfAL INSTRUCTIONS
Willed:
' h below land surface: 24a.Far All Wells: Submit ibis form within 30 days of completion of well
9.Total We] deft tans r di Brent&.Mple-3(a320 and ®I00� construction to the following ;
For Muldple wells list all dep f ff
(ft.) Division of Water Resources,Information,Processfng Unit,
r level below top of casing: 1417 Mail Service Center,Raleigh,NC 2 76 9 9-1 617 '
ID.Stfctie wale g.use„t
d is ve 24b.For Injection Wells: In addition to sending the form to the address in 24a
R 1L�re}molemt:ta?r: above,also submit one copy of this form within 30 days of completion of well i
on method-��i/�'��-�c�►/ coTutmction to the following:
2 WCB eO��b e,dueet push, 1
) Division of water Resources,Underground Injection Control Program,
! aogd rotary, ONLY' 1636
lye, Mail Service Center,Raleigh,NC 27699 63fi
VVELLS
. ��wAT SLIPPY
Method of test 24c.For Water SnaDly&Iniectinti Wclls: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
m) _
geld(SP completion of well construction to
the
county health department of the county j
136r. Amount where constructed-
�cgprt 'e-
.-
I jk4f Revised 2 212016 1
of Envirotrmantnl lZitality^Division ofM6ff
North Carolina Dcpaitmant-