GW1--05584_Well Construction - GW1_20230825

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1.Well Contractor Information: 1 -
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NcllCotumctarNamo MOD( To•: • DlstStmaolm ,
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1^5•O➢ ER-CASIIVt�ffbr�aniticasQdseells)OR LINER•(ftni.limbic):•-•.:-.••.: ,:-
Aqua Drill, Inc. .- - •FROST T® DIAMETER 1 •• MAT£Bmr.
ComperName• f� $ G.2 to-1'Sl3iZ�t C�v`
a6 INNER CASING OR-211BDIG( to tramielaseit:➢awl)
2.Well Constrnetion Permit �I-G-4.-l. to 3 mozan TO DIAMETER Trot twATrteral.
Litt ail oppifcabfesrell consnacaonpe,mics(ie.WC Coma% State.Varione�ate) f, ft. in.
3.Well Use(checkwell use): f ft. in:
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I Water SupplyWell
•• &nom To DmisTER •1.10.eisraz Tines:miss— BrATERiAL .
Agiiculttltel DMtmicipel/Public •- fu Lti ta.
Geothermal(Heating/Cooling Supply) residential WaterSupPly(single) ft'. t�
""(adusttiallCommerciat �Restdential WaterSupply(shated)
EO:TRODY'.- :..
hri lion FROM TO nIATERItu.' aitpaAiDEssreretoD�A►erotmlr�
Non-Water Supply Well: t� � qt, t
Monitoring �ua�.Ae,'. �C..r L`1,�[� .
�ry fu fa' cc.:Fs
I Injection Well: l
AgiaiferIiecharge GronadwaterRemgdiatior ' • ft,
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quell:St s ageond Recovery Sa' ' Barrier i9e g�tuorcit�v�b paCufaarattiratitc)
FROM TO MATtmrax• HnipLLAACFSit g4t98ttD •
uiferTest DStormwaterLongtime ft.
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Technology �SubsideaceConttol fi: frmal(Closed Loop) Tracer 20.DLEPIOEOG(aemd. dditiooalsheeesifmxe�an )rmal(HeadnglCoslingReturn) lOther(e,rplainunder'21 Remarks) FROM To nest rtorroxse;r emsmsv.ouctvee. simu_�
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ft' �� ft' CliaE'
4.Date Well(s)Completed: 7'�-3 Well IDS l a ft' &IS fa /
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So.Well Location: co. fr: ft.
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Facility/0wnerNamo •FacilityMO(ifepplbable) ft. •ft. -
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Physical Address,Citp.and Zip fft. ft. �' f Z--: a ...
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Cot- +�-- 21.REMARKS --. ; •- Lrt(t _e:•N•:rul3 ' . -
County Y Pared Identification No.0%0 '
' Sb.Latitude and longitude is tlegreeshninutesiseconds or decimal degrees: ""C r'P� P Una
Cfwelt field.one boron is sufficient) 22.Certification: •
Z�L Ca.,J:> •
16A(btys, d541)'N `(1OIZr zb, 1Gl,r w ,
G.Is(are)thewell(s)rPermaueat or DTemporary SigneNteof er�Well' neraetot Dine
By agog thee form,1 hereby me tam de licks)war(errs)constructed fa accordance
7.31s ibis a repair to an ernstinglve& DYes or DC with 15A NOW OZC.0100 or ISA NCAC 02C10200 MI°mention&aedan&and tiara .
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pit 1setrepairfill out larotrn+reiieonstractloninfomualonandetplain nature elk?
min'o�dr�+ tdhasbeorpnm�ldedtotleeu�ellorrmr.
matt wrder#2l tratarkssectlon croft the baelteftblsfottn
23.Site dtvgrern or additional well details
- 8.For GeoprobclDPT or Closed-Loop Geothermal Weis having the same You may use the back of this page to provide additional well site details or well
construction,only l.GVI/1 is needed Indicate TOTAL NUMBIIt oftvells conswotiOn details.Yon may alsoattach'additional pages ifeecessary.-
drilled: I
r SUBMITTAL DISTRUCTIONS ,
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2.5 Tom!well depth below load station: '
Poraudepiewells&stalldepthsifd8errnt(example-3@200'and2@IQfl ( ) con.Far Wells:Allthe following
Submit this fotml
9tivithiu 30 days of completion of well
construstctiontothefallowittg •
10.Static water level below top of casing: ')--a (ft:) Division of Water Resources,information Processing Unit,
lfanreriers!Isaboreeasinl&tat' "
1617 Mail Service Center;Raleigh,NC27699 I617 •
11.Borehole diameter. (' (eo.) 241).For inieetion Wells: In addition to sending the form to the address in 24a
• Lib Well construction method: +rbL truabove,also submit one copy of this form within 30 days of completion of well
at. ,�e, p�etc) consctioa to the followin I j
Division of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail ServiceCentcr,!Raleigh,NC27699-1636
•13a.Yield(gpm) L( Method of test: OrkiN•l• iVim zr - 24n.For Water Sutmly&Infection Welts: In addition to sending the form to
l�� a`e ®� the address(a)above,also submit one loopy of this form within 30 days of
136.Disinfection type: '1 Amount: Ti.6 'L. completion of well construction to the county health department of the county
where constructed. I
FormGW 1 North Cantina DepatementofEnvimmnealal Quality-Division°MinterResources
Revised 2-22 211E6