GW1--05568_Well Construction - GW1_20230825

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For Internal Use Only;
1.Well conteaaetor Information:
•Oary.Thompsoo ,
NallCootatetorNeme • - r+aoat ru: unssiots
J NC Well CommistarOoddiuinnNi®Ler
Aqua ®l7II, Inc. . . I onaitltCasiw tbr�alriae�tasveus oRL1NER , ;',;
`a+OW TO DIABOTEW :, fl1ATenbto:-•.•. ....
Company Name• ft `'/i,"' aQ i((V7��AIFAU►L
G S e• Gr AS ' .�r'ar a t pot
I6:MISRct1s11yG OR•T9uBiwG :_,2.Well Construction Permits i- FROM 70 > dosed:inn: :, ;.. ... .•
NESS L
Land1 applrcablou+el1 oonsrrocacurpermits(i.e.WC Cmmgs waft Verrone%ate) fr. ft. in.
in. ttTAT ra
3.Well Use(cheeitweU use): fe 1
I_Water Supply Weil: •
lz'SCiN;. ... ;• •
AgiicWttual M ei MOM To minim BLOT ffi
1pei/Pablie f6 it. in.
3Geothennel(Heating/Cooling Supply) it' 'dentin!Water Supply(single)
Itdustriol/Commerclal DResidential Waters l (shared) ►u. -
Supply 89 GROUT..
Non-Water Supply Wen: mom 'nre�auy :rartc�tgxrr
Irrigation
b fit. "2a & metuoDaAatatuvr. • -
Monitoring Recovery ' �� n F•1I
Znjeetion Well: f6 • CA,'ps
I..9quiferRecharge OGmundwaterAemediatian ' •
fa
r�Aquifer Storage end Recovery �5alinity Beerier • '•is:•§Anutit vt PACK,f imble ; -
Aquifer'Test ertonr TO n aretunr, wrtc©i�iacaseo3tan 5totmtvaterDrainsge fh
Experimental Teehnology5ubsidenctsControl f�
Geothermal(Closed Loop) Tim
• 2U DRD;L[NGIGOG tt,iebaddttiobntsbeemtf Geothermal(HeadnglCooling Reaun) Other(euplain under#21 Rcmarla) nr zo __.._ TrOBrwtor ro� � •
4.Date Well s C fa l b ft us ete�
()Completed: 7f—.�`a 2 Well ID#
6a f6
�aWeICLocatioa: 1 °4"r . Sri
�d' s Gr1�w i G
C.(,Ay-Ea N (do le. �-0mm-5 GS . 3�1
Faci6ly/0tdnerName d" :��
.� FaetlttyIDO(ifappGcobto) fQ ft.-L C 31 Rot,/ 1�.('(•e. &P. 1e wru ft( le w� fe q®� d q�A�
mrAddress. ty. d
Cizjp tt ft
1 - - -
Physical
�5 2l:REMARKS .
County 1 _f�",la�ll
Parcel identification No.GPM)
' Sb.Latitude and longitudein•degreesliuinutestsecondsordecimald Ittfcrwr.�ddn r°r s •
l:a:�
Orwell Said.one rat/1m b sufficient)
�' �1'� *�
v '� 22.Certification:
6.IS(are}the wel(s) 11'er Dram'mameat or DTeou.ry S%mum ofceetiSc4 W l doa�o, r I �`/�—�
Date
)'war Orem)consouctat In accordance
7.Is this a repair toancudddlingwell: Dates or o withI CA signing CO2C.01000rma orISANCACO2C.0at die 200IYe(1Catauuplan Standouts=Idm:a .
Ile&Erarepalrfillomknartn well canrmtglenInjormationm,detplola'rkenantrrgrill: ropyofdrisnzmrribat been proddedmdetedlounon
repair wider 621 tram&rseerian orals the back ofthtsfoma.
23.Site diagram or additional well:Walla:
. 8.For Geoprobe/DFrd•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 LOW-1 is needed.Indicate TOTAL NUMBER ofwells• construction details.You may aisoattacit additional pages ifneeessory..
drilled:
u r SUBMITTAL INSTRUCTIONS .
9 Total well depth below land surface: • 51154
1 (ft.) 248.For Ail Weiler Submit this fort within 30
Fornuthplewellslistalideptltslftgrerrnr(erange-4200'4nd2@„100) days of completion of well
4� constnictionto the follawim�
10.Static water level below top of easing: (ft:) Division of Water Resources.Info on Prot
Jfewerlew.I isoilm�een:us are'``4- 1617 Matti Service Center,Raleigh,NC 276991617
IL Borehole diameter: Co L (iD j 24b.For.iniection Wells: In addition to sending the form to the address in 24a
12.• Weil construction method: l''6 as r• to.,: /. above also submit one copy of This farm within 30 days of completion of well
r,•e mom�y,�,� y� consauctioato the follotving
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Undergroun d Injection Control Program,
1636 Matt Service Center,Raleigh,NC2769?d636
13a. field(gpm) 111 Method of test: Ci't-`'e.`1�'6"t`c.• 24e.For Water Samar&Injection Wells: In addition to sending the form to
13b.Dtsutfectioa type: lZ� ?pv the address(as)above,also submit one copy of this than within 30 days of
X Amount I i.0 completion of hell construction to the county health department of the county
where constructed.
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FotmGW i North Carolina Department ofEaviaoameatal Quality-DnfsioaontrsterResomres 1 Reaited2.ZL.21116
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