GW1--05569_Well Construction - GW1_20230825

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W '__LI MilL____u(�'_'}I®I (C_,In l� IForInternal Up Only; .•
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L Well Contractor lfaformatiom:
Ceri,.Thompson 14.WA eRztmras :. ,. . t. ;. .
ViaU CommctorName • , ;OM TO: • aEScaUFittttu i ,
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Aqua Drill, Inc. �sI :.01ROST ID R OR, air IIeohfe: ..
ER , MAMMA
Company Nonni• hart a ft. s rs' $ I (,zs� la' IS b 1... w V e...
L Well Construction Permitd: — �� •• �✓ riC) IG GORIOUBING igmmnrmat Osseo Iaup1:':..A L• -
FROM TO irommarmt. rintisilss list ail applicable veiloan treeYmrpermitsgm U/GCmmy,SeafGVariance eta) % M. ps,
S.Well Use(cheeltwell user ft. ft.
4V atci•Supply Welk • 1Z•SCt;t3EIN. .. �• ,
'a AgnctdtwGeothermal ® ,,,'GPaUPublie Feonlin st
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u ,6pmaeiza "TRIMNESS _srn eutr. -
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(HeatingiCoo1fngSoPWy) 0 -,denial Water Supply(single) fr. ft. ta.
industrial/Commercial DRestdeatial Water Supply(shared)
,ltriiatiaa '-H9{GRdI11T.. > ••• _
Won-Water Supply Well: mom xd �ynramouw aiav/a►��rrainnaonnwniwn:a`.
jii � 0 fL V .t• UeNVbw.Monitoring ti._t�Recovery fr. ft.' `Ps anAc� �`� .
agfcctton.Wellt 1
*AguiferReeharge it GmuadtvaterRemediation " • - f°
AquiferStetagetrydRecovery �5e1'urityBatrier ao nrottAdeLti'ACtmennrmtta • . - -
uiferT�t �IStotmwatef Dtaimege ft. ft.TO 1
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1 etual Technology DSubsidemee Control re fa
ill Geothermal(Closed Loop) EjTracer 1
'20 DRILIA NDLCG(and&adman]stuntsif )
Geothermal(FIeatinglCoolingReturn) 110ther(explain underR2lRemarks) FROM TO DESciuntaufaster.htshoortmilisothttatairdotho.esal .
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4.Cato 11re11(s)Completed: Co-1 WeEP IU f�
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§a1VeltLaeaftom 11 rc spa �S tovet�r st, I
�J('Rhy It) 9 $ ��3 tau 4 rr
cmcr_ 9S n " 'ara Gala,•,.% 4.
Faet7lylOaau•Non 'Futility 1DP(ifapplieablo) ft. n _
Pbyt[eol Address.Cityandtip ;.K+ram-1..u"2... (4 ft
5 21.REMAR cs
'tc�,s Lt,. . �. rfG2 ur= 3.
Caaety Pared ideaafeation No.(PtN)
Sb.Latitudeandioagiivdeio.degrecsfminuteslsecoadsordecimaldegrees: iv rite n r,CiSOG Vr
6frrdl fold.one taUfongissufficient) yyCerttt;enef„n•
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6.is(are)the wel(s) ermsuseat or Temporary Si a of A tiv Cbnuaamr � �'v Z
. Date
7.1s this a tonn misting Belt: �P �3,� ayetnIngr(clam.ikrceby care,that tka ralf(sJ rat Cum)consoaaredlaaccoutre=
repair g es or o with LfANOW=.0100orISANCACRC.020D•Well CanrtrurrIrmandar*affd thai o
i trainParAult'laramn+rollcvnantraMkrrp(auanorrdaptafridoaamaeethie coPyofeGKeadharhenprmldedtoextrdlmvttni mpahrcarder021 reaarn s:eat=aroat&ebar&ajthisjarm.
2M.Site diagram oraddidonal well details: I'
. 8.For Gcoprobc(DI'd'or Closed-Loop Geothermai Wells having theme You may use the back alibis paw to provIde additional well site details or well
coas4uetion,only LOW-1 is needed.Indicate TOTALNUMt3ER°Neils• construedon details.You may also nitwit additional pages ifnee
Milled:
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SUBN1PITAL INSTRUCTIONS
9 Total well depth belaw land surface 3 2-5
IoraodtlpletrellslhualldapthtsyrDBerrattewmphe-3Q200•axd:(a)100ry (�) um For Ail�PJeltm Submit this form!within 30 days of completion of well
b consstrtitdianto the following:
1RStade water level below top of casing: i.
Ijtouerkrel a abareearhn�era�; (ft) Division of Water ltesoure s,Information Processing Unit,
1617 Mil Service Center,Raleigh,NC27699-1617
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11.Borehole diameter: a (in.) 241r For Iniectiom Wells: In addition to sending the form to the address in 24a
• 17.Well construction method: !b ill cy A;/ abovesubmit one copy of this form within 90 days of completion of well
fie.augtrratsy,eocltorreatpash.eaa cottstmctioatothe'fbllotvhtg
FOR WATER SUPPLY WELLS ONLY: Division of Wafer Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC27699,1636
• 13uY3iti.YDlsinfeeield(gpmtioa) 0 T(� •7 t% Method of test: tz a6'iz6.• •�02Ac.For Water Sunniv&Iniection Wells InIaddition to sending the fort to
e• the eddress(es)above,also submit one copy of this form within 30 days of
type: Ataounf: 1 1-a,.� completion of twit constauclion to the county health department of the county
where constructed.
FomrGW I North iarolicaDepa t°fEacia:mum:1 r Chary i Bavizc82r22r2016
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