GW1--04721_Well Construction - GW1_20230721

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1.Wei Contractor i OT:nation:
Cameron Bazin It WA8ER7.t31+�`-+
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4518-A a R.
NCWe➢Contactor tkaifrcationNumba i17F1t CASs� iw eI1 ORLNRR(d bit)
Aqua Drill,Inc. rimls.O TO NG(formatti Dt�a RnaLINNE MATERIAL
CompuryNa� I(‘-) II. ii D' k `n" pri,
g�I t 16.IN CASING Oft•rus NG(geothermalr p)eel-loe
' Z.WtWellCoostraettan Ferffiit#I -From TO DU ns6ZEtt TRIMNESS MATERIAL
Idea!appl able well contraction permtis(Le.(IIC,Caw*:State.Yarianc4 eta) ft. f. la -
3.11re11 USE Peek WEll we): ft. IL
Minter Supply Well: 17.5CREEN '
.._—Y! �� FROM TO DYABR.i;tt MOTS= TRIMNESS MATEMAL
Municipal/Public fti it in.
FROM
(Heating/Cooling Supply) Reeideatial Water Supply(single) tt. It in.
°Industrial/Cotnmenaal Resid®sal Water Supply(shared)
1&GROti
�hrigation FROnY To MATETtIAL FnIItrA�r61L�[FLOD$AFIOltNr
Non-Water Supply Well: 0f' _2, l ft. ,-, VJ 5
[�Monitoting r3Recovcry R. ft. f
Injection Well:
Ac iferReeharge iDGrom dwaaaRemediatitm i
19.SAND/GRAVEL PAM Rf Mill=NO - i
'e r Storage and Recovery ©ISalinity Barrier FROM TO MMA'[EMMAL t{lSRr ACFMMe nlEIHOD
'ferTest QStamrwaterDminage g tL
Expt�mental Technology DSubsideace Contmi it ft.
Geothermal(Closed Loop) JTracer 29.DRILLING LOG(attach ad,fiHaaalsheets if necessary)
jGeothotmal(Hcating/CootmgReam) jOher(explain uadef#2mRemnrks) FRom in
DESCRIPTIONtmim:h4 *. tyv''rntamta»ae)
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4.Date-Well(s)Completed: 7/3/2' Well M# �p cj R �d S R Res
Sa.WeEl location: I( i_ Ef'9 c��n�+ RR h�
Fn3Gty/n7wmrtaame FaahyMg(if epplicable) R. ft. n�n�
19 inG 4 il Q, rM,064- ViT if (t ft. JUL d L U L J
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city t panel ro,mifntioaNa(PIN)
Sb.Lntibade and longitude in degceeimiautes/eecands or decimal degrees:r (ifwen Bold.mmIstioagi nuRe af) 22.Certlfipdoa:
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4.1s(are)the vre?(s) ermaneat or IOTemparmy Sigmmte oFCtttitial Well cant actor
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By st�+e thisfans,i hereby meter that the wags)MU(atra)eonrnuusd la aacmdanso
7.
Is this a repair an saleting well: GYes or No +cub ISM NOW 02C.0100 or ISAMCAC 02C.0200 Well Canes Standards and that a
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repairuadvft2t sttura,/a sesilw or on the back oJddrjamr. 23.Site diagram or additional well details:
S.For GeaprobelDFT or Qosed I aop Gen Wells having rho same You may use dues back of this page to movuit:additional veil site details or well
tmctian,only1GW-lisneeded.LndumteTOTALNUMBEROEwcIfs construction details You May also aitantt additional pages ifar.eee«uy,
Milled: ,9U1301f1TALJNSTRUCT(ONS
Fa Total well ra,ntuptem, andeptla 1ge as ttmrsm�s( v 3@ 2C �i ( ) 24n.you All Welts: Submit this fart within 30 days of completion of well
depth heber land surf=
construction to the following:
Ie.Static water level below tap ofcasing: Se (ft.) Division ol Water Reso
urces,information Preettssing Unit,
' IJwater/net it ahem enTIng.use+/" 1617 Mall Strvice Center,Raia�h,NC 27�9-161/
lydiameter:ge diameter: !� OD-) 24b.For Irtiection Waste la addition to sending the farm to the:address in 24a
O above,also submit one copy of this farm within 30 days of completion of well
12.Well oanstratllea method: 6 construction to the following:
Chi SIP.ems.oblq dtrostmsb.cit.)
ilivieloa of Water burns,IIad:gioand Injection Control Fragrant,
FOR WATERSUPPLY WELLS ONLY: ___5•Leil- ib3u Mm41 Sea vlce Center,Ralgla,NC 27649-1b36
or
13a.Yield(gpm) Method of tact 24e. Wa Sev etdian W In addition to sending the fawn to
II- the o ( )above,also submit one copy of this form within 30 days of
13b.1)isinfectionnype: �"" ff
compl an f construction to the ty health department of the comity
constru
FoxmGW.t ] tt[CataniaDepaimeatofEaviromomMQtuIty_Division ofWaterRemeoms
Revised 2-22 2016
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