GW1--03606_Well Construction - GW1_20230522

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Aqua Drill,Inc. FROit TO DIA11Ei<dt tmc MATERIAL
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FROM TO! DiADIEUR /SICKN SS MATERIAL' . .
List all opplicabletteg piutniction penults(i.e:IIIC County,Seat%Variance;dal
3.Well Use(citeelcwel use):Water Supply Welk . ;
NROiW IC AMMETER SLOTSr� 1711 iS MAIERiAL
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•5b.Latitude and•lengitmde indagreesitmfinutesfsewads ordethal degrees: L:;` a tiY'r 3 `r,
Orwell field.one lavioags sufficient) -- •22.Certification: - •
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6.Is(are)tttewetl(s ,Aii•ertnanent or E3Tesnporary . SigaatateofCeuii6ed.WeIlConhador Date "
op si niz'a.hts;foie!hereby a?rNf•+6nt tho:*!rA(a)wa,`(.;c vj.mrestru pi 4i:aew,dmt¢
7.1s this a repair to an existing welli IDHes or" o . with-MANC4C 02C:0100 or1SANC,620io20o Wail me lorrStmrdarrls mrd skit*
If thisIsarepalijill out bwimSvei[constritetionmf - =Id explain the nabi eofthe COPYoftreogrd> Pm 0 thew1Iips .
repairuaderEZl remmi'msectlan oroa skit bacboftusform.
23. titliegram or addit3o webt deter .
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B.For Geolerobenviror.Clos .00p Geothermal Wens li4;vingthe sam•e You May use d!e hack of tbts page to'piaviide additional well ate. details or well)
construction,only 1GW:Iis needed:Indicate TOTAL.NUMBERofwells : constrdctimtdetails YonmaYatsoattararadditianalpagesif
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drilled: !, SQBMfiTAL INSTRUCTIONS9 Total well'deptb below land sui facet 2!j . • _- (It) 24e.•For All Welis: Submit this form within 30 days of-completion of wet
For=dil*wells lis adepths iffiiffereat(ale-3@2000''a and2©1001 _ ' . eop�gction to the following:
1e Static water level below top of casing: v (ft) Division of Water Resources,Information Proce rig Unit;
Ifivater level is above casing use{ • 1617.Mnnil Service Center,Raletgb, c 17699=1617
-11.Borehole diameter. _ • (ID.) 24h.)oriniedlon Welke In addition to sending the fonts to the address hi 24a-.
above,also-submit one copy:of this foam within-30'.days of completion of weft
12.Wellcon. astlontmethod: Vley - - ednstmctioatothefollo� i
CLe.airs rotaiyi cable,dmeetpasb,eta) i
Division'Of Water Reseaeoes,TUndergionndInjection ContaoIProgran,.
-16161 SereieeCenter;Rat .,
FOR WATER similar WELLS ONLY: center;� e7gb,NC Z7694�636•
13e.Yield(ono) � Method oftesls /3Gt% . 2t For Water Snooty&IniOetion Wells: In addition-to sending the fo�to:
/ 'dieTaddress(ss)".above, oleo.submit°one-copy of'ttiis,'fogy within 30 days of
13b.IDisinfee>son type 1 A>7aotmt: L C -. completion of well cansttaction l to.the county heailh;depardment of the county
where saastruct d.
worhCaroti ape ofEnV �Q "O OA ofWeterRas Revised2.22-2016
Form GW-I , 1