GW1--05585_Well Construction - GW1_20230825

POT Internal gJse Only: . -
L Well Contractor information: • _ .
•Gary.Thompson
WellCoannetorNama - • MOM TD: • Dscau►nuty i :, ;
4418A • • l(06,fz 14?& F'f-:•cta1"; .-a •teal* .
f
NC Wan Cantm t Ccennon' O= I.
Aqua ®rill, Inc. .• . of uTitit�INta(ttn�al�:e a.;ve�)oRLiNERtaa�'tteaula): -
DrMMER r •. ItfATlRMI.
CompoayNam°' • t] it ' n,iS` I Co AC- ln. I S�(ta< ,pvc
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2.Well Construction Permits ��� 16.EINE R�LYG DR- G(Qeatheemel deseit:Ia6P): ..
mar To nrantETER ?�cr¢yess a�Ts+mnv'
Lust alloppffeabfatrelloorsrnucuanpemrics(Le.WC.County,State,Variance.ary ft, � lo, - '_-
I 3.Well Use(check well rase): •
� R. ia.
Water Supply Well: _..
IAgiicultudal FROM TO amass. . [1114TEnrio.
I1I t :bipal/Pablic ft: ft. MOWER SI.41T9LZ6 ffi
=Geothermal(Reating/Cooling Supply) I'Residential Water SttpPly(single) ft• fe in, •
Industrial/Commercial 0Pdsidential Water Supply(shared) '
Iarigation •11f.DR09fd°.. s
Non-WaterSupptywell: a7tonl. TO nmTFsmy arenronsiesiouicr
on-W ierS �I Recovery f4 r4� ,;t"., p64.1 r -) 14 ,
Injectioa.Well: �' fG
biter Recharge . ft f CO J�5
Q�Groundwater&mediation ' •
•
�� quill r Storage end Recovery �SelinityBarrier •t9 6ANI PACR•fifaarufeotdal -
r FROM to
*Aquifer Test MATERIAL j� � nti rgon •
�IStotmwaterDtainege ft. � • �
AiilExperimental Technotog EtSubsidence Control i
Geothennol(Closed Loop) OTracer '20.DRaLLINGi.QGtaeiichaddtsonel sheets ifoe sere)•iii '
Geothermal(HeatinglCaolingRetum) rfiOther(eapleb:under#21 Remarks) 51
11
1)
1 ft. To DEsctorrfroxtwmr r�mmas,s wfrckum e�eize-cm)
0
4.Date Well(s)Completed:V"5- Weil1D# ft: f`
l� !lJr1, Sisneeit 66r •
Sn.Well Location: 9 L 1
CC Nev.. �lr,e~ IA k1ke f6 1t,s ( trr.�d•e e
Facility/OwaxNaQto Facility DU(ifarmiiwble)
GS 11 1 lS '� G�tAr,,-��
t.a .tk)S Ric0 . RA, uti•�S k!.> ft. ft. . P #-4 c ri'v n
PtyrstmtAddcerc.CitS:aadiaap • ft. ft. 'aP ® `t�°
4'ori•y-/`{. .
Z1:RBIt?ARiCS ..
i Alit 2-I'202
County Pared Identification No.(PIN) i• 1
• 5b.Latitude and longitude intlegrew/minutes/seconds ordecimaidegrees: 4�(pr an ?r^c. :frg Uttfc
given field.one IatRong is sut6ciea0 ZZ.Certification: i lSbb i.i ixOC•.•.
IV;`2 p(r t 'S14 N S.'S r II t r-i. ti St4°1' W ,
6.Is(are)the wcll(s) er nraaent or Temporary •atgnetureoft.eR••See Well Con curs , Datc
� BYsignTS tlas famr,!hereby certi.den the Trellis)was(cent?constmuedta accordance
7.1s this a repair to we existing well: DYes or g4 Wo With ISA NCACOWC.0100orlVANCACO2C.0200 Well CormrocdonStamdardsand that
IP asisatsepale,111Iautlarotrnur!IcnasnucrtonhabrmaUanandr plahithenattaeofdte CM'films=What bon provided to Omen.omen
repair under 1121 reatardrarcdmr area the bade of dds•foam.
23.Site diagram or additional well details..
. L For Geoprobe/DPT or Closed-Loop Geothermal Wells having dies-ampYou may use the back of this page to provide additional well site details or well
construction,only I.GIN-i is needed Iodinate TOTAL NUMB R ofwells construction details. You may also attach additional pages ifnecessary..
dulled:
SUBR4[l11TAi.INSTRUCTIONS '
99.Total well depth below load surface: ' 1-2 5-
.rnuthi le l b depth c}dservo(erainple-3(a,209'and2Q100) (It) 2dn.Far All Weft Submit this firm within 30 days of completion of well
construction to the following:
10.Static water level below top dosing: U i
lfnnterlelrflsabateewsing rrse" (�} Division of Water Resources,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276991617 •
1L Borehole diameter: (P rm]
246.For Infection Welly In addition tO sending the form to the address in 24a _
V.Well caastractian method: f't7lb�l (�-.�r above also submit one copy of this fo i within 30 days of completion of well
(rc.auge,m may,cable,trrectpush.etc.) cofl5hvt0iot►tothefollo�vina
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276991636
•
13n.Meld" tie) S- Method of tub 4-06^ ' °�''-e- 24c.For Water Sonnly&Injection Wells; In addition to sending the form to
Oo f 4, the addresses)above,also submit one;copy of this form within 30 days of
13b.Disinfection type: t't 1 � /Amount: i Jo/2- completion of well construction to the comity health department of the county
where constructed.
FormGVl=1 North CoolinDepare rntofEnvironmemalQaaluy-DksioaofWaterResources Revised2-22-2016