GW1--05571_Well Construction - GW1_20230825

CONSTRUCTION ONSTRtJtCTION fly+C121)irGW 11 For Internal Up Orly: g t®rat.
1.Well Contractor faformatiai
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GaPli.j lq®9Si11Rs®n 24 WATXft2OprES•':.. •.. .......' • .
Well ContrnetorNeme PROM TO:' • Dr'SC'aIIrIYON
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4 1 A • • a t i) re. l i t- ce-tan!-: •X c la,''^
NC Well Connectarf etd&eotiantaomber I.
Aqua Drill, Inc, . •
is:o R°CASINGObtr,d d.welts)BR x(o..- :•-•••• :-•••
"mom ro in.DIAMETER
Company Name• • Cy ft "rib t� I
fo,].g-' 15 O(�L'. PVC
Bet • 16.litINEFICASIND D)t•TUBIINGkinibarmalclosad4atin):::' '• :,• : -2.Well Construction Permit#: s... ' FROM I TO TalC •
adadall oppltmblewel wmtn+cuonpemtits(t,e UIC Cotmry,State;trariance ate) fft. ft. I DMt um bt. u.
3.Well Use(cheek well use): D. it, I • in.
Water Supply Well;
Agiicallaral cipaUPablio •
moss r =ili 1 Bt*TSi3u .Ti:`. :. ..
fe: r1. raS rim%
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single)
• industrial/Commercial to• ft. te, ,
DResBdential Dieter Supply(shared) •..".mow tow.. .
Ieigation FROM TO -'atATEaf*L~ m1PI1cG(tuiter Maim `-
Leon-Water Supply Well: • bhy�Z
Ivionitoring RecovFn�� N1t3.
7njection.Weli: ft. ��•`ps
Aquifer ft.
. OGroundwaterRemediation '
quifer Storage and Recovery OSaUttityBerrier • 9lSAtvttt&RtsveLpat3K{,Fntmtim6to);
FROM To minium , anciou er»on
• guitar Test 5tottmvaterDreirtage ft it
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EExperimental Technoiogy DSubsidenceControl ft: . ft ,
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Geothenncl(Closed Loop) OTracer .20.BRISLING LOGfaemcbmtdtdtnni sheets if )•• •-. : . -
Geothermal(fearinglcooling Return) Daher(euptain under#21Remarks) FROM TO DFSena!tnONLsQloa:trmdnemsolVenakOnmmaoym,om) '
G a f` ls` ft. c(�9
4.Data Well(s)Completed: bl-�` 3 Wen UMj - fc i)
dn..Well Location: t' ' ,�me .i �"t�� �e
1 Cr'� �7D � �(`la ri:t�' � .
1°kvki. c it Car- t"1,,iNviA.A;r•.. t � ktS `a D fe � - c.-,.am,;:17e
Facility/0anerNano •Facility 106Sfapplicabro) ft. ft IFrz0.0%rz ,�
't,�.a.-�l4 C., Suro...,kllt (t, Ike9 ft. tr. . e a.R
PilotedAntheee.Civ.ondrip 4ti.:Lk.s'� NC 2)8`G 21.itE111�Rt(S AUG 4 i➢ ZOZ3
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Corey PmeolldentifiesdonNa(PIN) Irk-iniktate:a tPrc-,,,: 'Y.a:'3•U6 i
5b.Latitude and longitude in-degrees/minutes/seconds or decimal degrees: •
• '6"t'jam'
Orwell field.one iatllong is sufficient) 22.CerUtitatlon:
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'�6�' -1 9' t 1, �tSiY3t pt pia a`�'r.3�f.sr 3 s tt"' w
6.Is(are)the wef(s ermauent or °i'emporary SignataeeoF eel Well Con r D Ic-' `
•
By signing this jars,11:ereby care that the rrall(s)rot(tore)constructed fa accordance
7.Isthisarepairtoanexistutgwell: Dyes or Ell‘ with 15ANCACO2C MOO or15ANOM'02C.0200Wel1Calm:r aonStaadanfsmrdthata Pia&art:palr..1111a thnotrnt allcmuuacfocirformationandecplahithenatmeego coPY°PUT Reed Iwo beg aprorldedtothet dloa»er.
rapairunderMI remarks section arcathabae&oftbtsfarm p
23 Site diagram or additional well details: .
. 8.For GeoprohelDPT or Closed-Loop Geothermal Wells having theme You may use the back of this page to provide additional well site details or well
construction,only I.GW-1 is needed.Indicate TOTAL NUMBER ofwells• construction details.You may also attach additional pages ifnecessary..
• drilled: i SUBMITTAL INSTRUCTIONS -
9.Toot well depot below lead surface: • 6-`� ft
Far nadi)*wells&tallchol Vitrr=(,sample-3e200'and2000) ( ) 24n.for Rail the
Submit this form within 30 days of completion of well
construction to thefollawittg
10 Static water level below ro casing:of
ljuaterlereilsabarernsing:ate dp Li (ft.) Division of Water Resources,information Processing Unit,
. 1617 Mail Service Center,Raleigh,NC 27699-1617 '
• IL Borehole diameter. (in.) 24b.,For Tniection Wells: In addition to.sen
ding the above.also submit one form to the address in well
• 12 Well construction method: a'O e•y A. r. copy of this fans Within 30 days of completion of well
0.e.atom way.calk.direct push.ern) consuucdon to the following:
FOR WATER SUPPLY WELLS ONLY: 1636
of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,leigh,PIC276991636
I
13a.Field(gpm) Method of t �c1• i`''" 24c.For Water Supply de Injection Weft In addition to sending the form to
`� ., vim✓ o the address(es)above,also submit one copy of this form within 30 days of
.13b.Disinfection type: !a Amount: 1 ' /4-- completion of wen construction to the county health department of the county
where constructed. I
Form GW 1 North Carolina Department ofEnviuoomental Quality-Division of Water Deselects Revised2.2220t6
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