GW1--04890_Well Construction - GW1_20230728

-®w` FQT Internal USE Only:
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I' ^ Caniueturltrormalton _ .�'u..�P •.-.
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FROM TO F:t�;E7 iV
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1 , dcWellCoahsctorCasti6cszonNume ig.OUTERCASING(foru rani-fa.13c.'�ti)6�le.n • ":rT^ v xa .
Aqua®rill,inc. FROM ft.. f
0 (/9 it. & Ia. 'rh"7' _ �...
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le.1NMRCASING O1R TUBING(Er:hems el e.tst 9-'_
2.We31 Construction Pemd6M "0 N€3Z FROM To I mP3 um-i-ae 7sslz�ar: rhtas, 3.•s.,'
LLt all applicable ueU aasshucth2npezraits(i.e.(14 Corinth Slate.Parmtee,etc) it. fb in.
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3.Well Use(clseckwe3l me): fc. ft:1 to _`H ,
17.SCRE€1V ,r.�Sbw 1 M<�n:...`L-.�
Water Supply Wel FROM 70 err a r� SLUT,? ,^ __
f.'>'caltutal ON6mieipallPublic Ft i en. •
1!Geothermal(Heatiug/Ceoling Supply) •syi'esideatial Water Supply(single) ft. ft. in. 1 1 1 i
ill IadasttiaUCnmm eial a Residential Water Supply(shared) --_ '
H.GROUT
)4',.. •;on. FROM 70 rlATdRINI. Ltuedat72'u �t o3P...,1�,_,. t
Non-Water Supply Weil: 0 ft. 7 2- G(,a' 1 firf i1 i
OP idianitoiing Recovery ft. it, ;a •
Injection Well: a. I i
lit'• 'far Recharge DG:o>mdwatarRemedittion
19.SAtinIGRAYEl+P[t�..b{K'r*uili le)
.• -'Storage sad Recovery oSatinityBaffier FROM TO 6Aah?NA. I FiKim.AtiyestaaamR7,2,^
-Test 0StomeraterDrainage ' tt. se.
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*'-...crimental Technology °Subsidence Control It a' { ---1
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i It Geothermal(Closed Loop) "°Tracar 20.DRYr.1.II6G LOG(2t7r'sb sat earl a4cals iS lea'„-'�� ;TT!
FROM I 70 _pkz.kurtlola(ezr,bxmfnr.�.W^Ja....“-"+FrZ 71'.1 .---r
N.creatLetmal(Reating/CooliugRsttan) other(esplaimannder#21 Rem a>�) 0 lt. h S s� d E
4.Ante Well(s)Cm-Added: - /2.e/0 2Well MS 5 R' �o t C r 0,p ---t
� S QS � R ft.
Fos&f/0llmerNnme Fealty rPpLwbrc) ii !i sl nn1n
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4l a Ar r exSo • { C ie .4-
E. !n ter,;:: i';- ..,�,;., Lin• Physi al Addnes.9a"ty, v1=dlJ - t
is tl�t/i • 21.RED/UM
County " P 1ldentWe dos No.(PIN) `
Sb.Latitude end longitude in dcoreeaalmlantes/seconde or decimal degrees: Certification: {
(sfwelt field.item Indla�gis sufficient) 22.1
..zzz,,,i-i/f.-2 3
Sigutusu ofCcn al�Yei Contr�tor a s
• 6.!stare)the wet(s) ertsaanent or DTeauposary
By signing this form,1 Web,00mJ).that the mil(s)was(csere)constauctot 6:G.:7 .:,c6
7.1s ethia a repair to en existing wen: tares or No with 15A IfCAC 02C.0100 or IBA NCAC 02C.0208 Ifv'l COnstr term Ste rue z-rd etc:c
Otis is a repah:h71 out Exam welt coadr eliaa Informed and esptain llse nature gfthe ropy aphis record Len keen provided to the we owner.
- ,ya(r under t21 remark sectionDramthebackoflh'sl 23.Site din mar adthtietiCd well dellte
You may nse'the back of this page to provide a':.;Gaul::et:l Lite d r its.•v.radl
S.For GeaprobelDPT or Closed-Loop Geothermal Wells having the Fame construction defile.You may also attach adsi. ca=r pas:; n = 1.
construction,only 1 GW I is needed-Indicate TOTAL NUMBER ofwells
data: ,R[T_GA +1N ITCTlONS
9.Total well depth below bad surface: 30 S (D'.) 24a par All Wells: Submit this foram within 30 days of compleat�of well
For m,idple wells fist all depths dWrmn(excargle.WOO'and MOO) construction to the following:
10.Static water level below top of caring: Y o (IL) Division Of Water flexources.,In erinr tiou?rovrAng Waif:,
!fureferlevet is above=dup"use+" 1617 Mail Service COetel',Raltdgra,NC 27£:0*31617
6 (�,) 24b.For Infection Was: In addition to saiding the form to the r i cs in 24
11•Borehole above,also submit one copy of this[saint vflti3ia 30 days of cs:mriasgcw af'old
12.Well eonatrasede s method: (,-d-c ry construction to the following
(La.c.attger.tialatY.cable.cruce.Pusb,°`) Divisme of Water Resources Underground knjoctinn Contuei IN-mgram,
FOR WATER SUPI LY WELTS ONLY: . 1636 BUR Service Center,Rat gio,NC278 -1636
13n.Weld(um) 2 S Method of tear i ITl1( 24c.For Water.SetM19&loieegou_`Wplln: In addition to ssmdz5 e e foam to `
(� the address(es)above, also submit one copy of this Eosin n�ttuin_0 days of
13b.Disinfection type: � An1tt �'��- completion of well constract'iom to the county health department of the county
whore constructed
FortnG44t-1 North linaDepartment of Environmental Quality-Division of Water Rrr mens Fars:i2-22.2E-6 '