GW1--04085_Well Construction - GW1_20230622

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WIELL(CPHSTRU CTJI®PJ EEC lIRD(OV/4) For Internal Use Only;
1.Welt Coniraetnr Inforanatio®:
• Oa f.•!homy oIl 14.�t►ATEIBZCDIVBS
Well Coat ncttarName • . F11®ni TO.: . DESCREPTIOAT
18 A • 16 a 1t'a I it Crpc.t- —. (.;.p
1 ft.
;IC Wolf CoatmceorCet¢i&eaaantaeaztet IlS:®lOTBI&CASlRTts(ths°EIaitioCaMaBrtFliO tDRILEVEtz rfap'1[eflFrF
Aqua NIL Inc. .• 'FROM 1 TO >rsg•• tuata
Company Name• • 6 it 1 4„ a�.(c DIAMETER,1, .e.�!TRIccnv 1 (J;,1$,,
1a>[iDV ut CASINO CI lIMENO feeotbermalclned aco):'
2.Well Construction Perna#a e_•® d 0 6-45 rzt®na I TO DIAMETER Tancitemas flT T EI as.
Da ail appiteahle wall conornettonpermits(Le.UIC.County,Starr,Variance.ate) ft; ft 1a
3.Well Uso(check well use): fi: ft 1n.
Water Supply Wall: 19'St �+3V. ... •.. _ - .
• Pet®;� To SLT - SLOT s 27Rernerbss ; MATEMAL -
Agricultural E3 , ••cipaUrPublie Gs at. en.
Geothermal(Heating/Cooling Supply) gi esidential Water Supply(single) ft R. in.
Industrial/Commercial - lltesidential Water Supply(shared) ..lis.cam.?.. . . -
•• Irr tion lr®na 'fa MATERIAL EMPrneenNtat• TRrsAAn®tmT•
Non=Water Supply Well: 0 fe 1.=1› Ge
Oc o'NE. pp.,r Faye
tvIbnitoring : Recovery ft, ft • 1`4.0 s
Injection.Well;
A iriferRechar a SG f�
9 S �GroandsvalerRemgdieldota
Aquifer Storage and Recovery Salim 138tt16r •19.SANDroRAITEI PACIC•trra rmala) ' - ..
O •ty Fans To manta mr aPi aa:mtgrraEreom
Aquifer Test OStormwater Drainage ft it.
Experimental Technology liSubsidenceControl ft, ftGeotherrai(ClosedLoop) DTraeer 2o.DIt�LseG7LOGfatiuehaaaldoiialsheztrtf�ecsaep)
Geothermal(1IeatinglCnolingRetar) DOthEr( plain umdee#21 Remarks) gaoat I TO DES
tas>g+ataet War,r °e,, t„ca �srrs.etat
0 f6 k b Sr. 1
4.Date Well(s)Completed: Weil DV •
t rs fe' S 5— r 1 .,Ge eyt1 5 e-r•°i
9n.Well Loealion: 55. " C,''' fl. C;�;ar%1 Ire. •
de,.,S4Ta 93 V.tisd UnfxNuY� fa�j EFa 1,j"�S f� l�ro:.: c—
Faenny/OtmerNome •Miry ID0(ifappiicabte) ft. ft.
-71 sty 6`.e }A''.vim
`Tvves- Q4• 11:/,,a `
r p\ ke,\\ INC "rib'i " ft re .:i R 9
PBya[CalAddtresa.Cay.mdZip ft. ft. L ' ..r c �' •—•. ,• •
curS T� 21.REMA1UfS .. • ^ " 7C2,
County ParcelldentificationNo.(P1N) • ,�1jIV J
' Sb.Latitude and longitude in-degrees/minutes/seconds or decimal degrees: .. sin roc ('
(ifwell Reid,one tang is sufficient) 22.Certification: *riTM VeCtl ZTErs
b 3P1t<11, 2-2-1-0e N SD 6S' ;:x. l;1S4ri w
ram/` ►,�( --i d 1'1-,. -
6.Ware)the well(s) `ermaneat or °Tempos pantry Si :of tifie4 Weil Caottnetor Days
ay signing this font,l hereby carp Ara:the well(s)was(irgre)constructed to accordance
7.Is this a repair to an crating well: DYes or ofT. with 15A NCAC08C.0100 or ISA NCAC 02C.0200 Nell Cottstracuon Standards and that - •
ifhisisarepaI.fill ant known well wnstnrwton informat(enand esplaln'rhenanrre of the copyedits recorrdhasheen prorddedto tlreurdl owner.
rspatr under#21 remark etton wan the backoftdsfarm. 23.Sitedi
agram or ad• ;mai well details.
. 8.For Geoprobel PT 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 l.GW-lisneeded.Indicate TOTAL NUMBER ofwells• construction details. You may also attach additional pages ifnecessary..
drilled: r SUBFIEITTAL INSTRUCTIONS -
1
9.Total well depth below land surface: ' (ft.) 24n.For All Walls: Submit this fora within 30 days of completion of well
For mrdrtple wells Avail depths ifdfffe ent(erampte-3@200'andl@100) construction to the following:
10 Static water level below top of casing: 5-6 (ft.) Division of Water Resources,Information Processing Unit, .
ifuaterlerelIsabaterasln%we'•=•• 1617 Mail Seretice Centers Raleigh,NC 27699.16'17
•
1/.Borehole diameter: 6 (in.) 24b.For inieetion Walls: In addition to sending the form to the address in 24a
• i above,also submit one copy of this form within 30 days of completion of well
- 12.Well construction method: f r rM.4 A f- construction to the following:
(ix-auger,minty cable,d$ect push.etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATt R SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13n.Yield(gpm) S-- Method of test �wk- -n 24c.For Water Suanly&Injection Welts: In addition to sending the form to
- o 6. the address(es)above; also submit one copy of this form within 30 days of
13b.Disinfection type: ' 771 Arnoanft (2 / completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEtwimnmentel Quality-DMMsioaofWaterltesources Revised 2.22 2016