GW1--05570_Well Construction - GW1_20230825

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WELL( O1�TS lU ®I�t1 (C®1 .Im9 i .�•rrinit� ®tm:
For Internal Use Only:
L NrVelt Contractor Information: •
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GOl]/•1�id899 OV1 sa.WAflERZbRrhv•;:,• .
Wall CentactorName DR • 1 1
NC Wen ConlanataeCeeti6ea6enN®tea• I t
Aqua ®aril, Inc. . :ISS NTltx• mlGtto nrnl avelitlOR1.>n�t . u aWc.'-...=:.
CompanyNamo• IITAMEAL
6 I l-5 i')tt I G i 5 S` In. I I 4: ..% PVC-
2.Well Construction PetTait3k S° •� • 16i. RI
INNEN CASING OR-TUBING Eotheru al dosed:leas)° ••:•••••••
FROM TO Dmtnarroo . TRICr moluturfa
LWa!1applreablaueltrwnontastaupermgs(Le.WC Coin%Stae,variance.etc) fr. ft hit.3.Well'Use(cheNcwell use): ft. ft. • an.
Water Supply Welt: 17'SCR EN:.•...
Agiicaitutal �Municipouwumife FROM TO 'WARIER WIT-SIZE TRICE SrATCM%
ilk •
ra.
*,Geothermal(Heating/Cooling Supply) Waldential Water Supply(single)
iii°IadusedalICommemitd ft �� _
[31,42:Mends!WaterSupply(shared) •.fl0.GROUT.. -
' iInigatian FROM TO a Mt.1E$rt1L ' • '- ;
ikon-Water Supply Weil:
, � t" teaAcnn�rateaxoD�AuaotmtT'.
+' ot»toring : C7 a �b cUc-t�a1.,i lc . pa;,�I NQ,,
Recovery ft Cb�Fs
Inicction.Well: -
11'-gitiferRecharge OGrotmdwaterRemedietioa • •
fr.
•�AquiferStorageandRecovery �SalbulyBazrier '9=•S eni vELPACic(,fapntieeble) i I. • _ _ .
IB•quifer Test paom To asaTEnrAt. +>sCm�nratEr�on
QiStormwaterDrahaege • ft: ft •
. 'Experimental Technology 0SubsideneeControl . ft. ft.Geothermal(Closed Loop) - DTracer "20.DRMLING LOG Winch addtdaoalchaos lfuaresurv)-:_,Geothermal(Heating/CoolingRetum) tOther(explainuader#2lRein:Ise) FROM f TO nEsaw•rsmrtemnreseeoa:evmrrctsaawens .ago •
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D `D C-lv, 1
4.Date Wel((s)Completed: 6."1'•`1 Wen IDft tt
Sat.Wc11 Location: .�`� ft'
` � 0 fy s�:A Y 1
SA-Imwt t �
FdcilitylOwaerNamo r'r Facility ID0(ifappiitabfe) il �� �'`a� z I . d �7, i
-Oat�y 13a tt).5 GsAai-U. 1._e i�9AtLP
Le.� (c_2r'a (✓-. ,l haL..A Lut,c. U '1.—it"2- ft 4t' I' 2
Physical Addem.Cdy.aadZip ft. i, AUG G 2023
ei-1'kl k t_s •
2a:ItEn?ARI�
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Calmly PmeellelcntifiwrionNO.(PIN) ttt(irp8te'3:t ar r,,,,...,..•s•v. .Ut•`. -
I Dykft in
5b.Latitudeand longitude indegreeslminutes/seconds or decimal degrees:
Orwell SAL one bansissufficient) 14
a 22.Cerdficedoa:
6.IIs(are)the nrell(s} ermsanent or QTemporary eqW —l -�3
Si of erti5 Well ahacror 1 Dam
7.Is this a repair to an existing well: By signing t ds faint,I hcrcby:crr&that the ml1(s)was(tern)eatis0oetad la aecardmtee
grj)!es or No withISANCACO2C.0100ar15ANCACO2C.0280trellCotrstraedouStindardsandthata -
Pat iIamotr fellrmtlarorrnwellcomhacrlaa ktfonnatIorzondrxpkin'titeatmuetithe mAyaf this reco an been PrTivadto'hue eti lea. •
sapatr under 021 ra amrks s eetaon open Maack of thir foua.
23.Site:Hamm or additional well details:
. 8.For OcoprobelDFT 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-I is needed.indicate TOTAL NUMBER ofwells• construction details.You may also attach additional pages ifneeesmry..
drilled:
SUBMITTAL INSTRUCTIONS I, '
9:Total well depth below land sttriacm 1 Z�
Fornuthi le depuall , (it.) 24n.For All Wells: Submit this farm within 30 days of completion of well
p depilisyityemu(«ample-3C3�20�}0�and2®100) construction to the following I
10.Static water level below top of casing, "'t,1) (ft:) Division of Water Resources,JfunterleeelL5.above owng are"-" terInaleigh N 2769 -161Unit,
1619fUIsa�SesviceCen4ar,Ralefgh,3+1C2769411617 •
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IL Borehole diameter: 6 (in.) 24b.For infection Wells: In addition to sending the farm to the address in 24a
• II Well construction method: J'b tZc�Y f above,also submit one copy of this form within 30 days of completion of well
(Lc.auger.matey.cable.dueetpush.eta) a onstttictian to the following:
FOR WATER SUPPLY WFQ NA ONLY Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Rntefgb,NC 27699-1636
• -3a..><ield(gpm) <1 Method of test: C.A P l 1 4-O%-• 24m For Water Sunniv&Infection Wells: ,inI addition to sending the font to
-f. ;,1 a z v the address(as)above,also submit one copy of this form within 30 days of
136.Dismfeetion type: A l Amount (6, it— completion of wail construction to the county health department of the county
where constructed.
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FwmGW 1 RanhCarolinaDepartmentofEnviraomenttllpaality-DivisionofWaterResoun•� Rev ised2-722016