GW1--05929_Well Construction - GW1_20230918

'WELL COMM.UCTECD1g -2141
For Internal Use Ontr: —-- s
1.Well Contractor Information:
Gail,.Thompson ps® l 11)Y4`wAT Zolvas .
Well ConttaclorName Pa00t TO. DESORPTION
4418 Y a 4 Db 'a. c-7/'.0.-.,.^.7 r +"
NCWoUContractorCmti$eotionN�i¢r C'.1? "'I 6�Ae V, y.
IS:OUTER CASH%(forum) l RL1NER(d -neolde): - .
Aqua ®rill, Inc. .
PROM 1ID D TRIMNESS MATERIAL
Company Name• 0 it I �tf5 ft' cP e La• in. j(,)?,\ t P teC
1 16.INNER CASING OR-TUBING theratal elaswWoap)2.Well Contraction Permit:&: -) (geo
_) PROBT TODIMMER Lust all applicable nth'construction permits an.WC.County.State,Variance.etc) ft it la. �CIOniSs t
3.Well Use(check well use): ft ft. in. _ •
Water Supply Well: •
17.St�tEp11.
Agricultural RION TO _DIAMETER suntan THICKNESS MATERIAL
M ipal/Public ft D. In,
Geothermal(Heating/Cooling Supply) Ottesidential Water Supply(single)4ndustriallCommercial fe ta. ,
Residential Water Supply(shat'ed) gg,GROUT..rrigation &ttOPT TO AfAT£RlAY. ERYPLACE99tM':(afoot-Water I,rO� aT�mo&AMOUN 6-
Monitoring oRecovery .l ft R° Fl r.:,P S. t:� �6.. y D
Injection Well: ft • J, p a
Aquifer Recharge JGroundwater Reimediation et ft
; (Aquifer Storage and RecoverySalinity Barrier 19 SAND/GRAVEL PACK appt ) •
FROM i to BIATERIAL snmaaCEntmvrAmmon •
:aquifer Test DStomtwaterl3eaiaage ft. ft.
+Experimental Technology QSubsidenceCentral ft ft —
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(atiuch additional sheers if necessary) -
Geothermal(Heating/CoolingRetu n) FtOther(explain under#21 Remarks) PROM TO Ass ttoav�o�m;I�,ao os aenl�octasme rra;n ere)
0 (1) ft. (J%Mr tl'
4.Date W ell(s)Completed: ?r-'7'-?4::.-.' Well IDp r h ft ) ft' .1 10-
511.Well Location: (A ft ft. �• 1
p(, G� VEC•,.1/ e
Y)fa IN)/d sJV►"\l <' e- ft ft
Faeility/Ow Mime Mime Facility IBM(ifapplicabte) ft fr.
5 er z1 .S "vL.\ Cru.t ems k94. `�i htf( 1'VG ft ft
Physical Address.City.and Zip ` ft tt -
S A-6 ke,C. 21.REMARICS . i../ 1!1� ~L.,
County Parcel identification No.(PIN) 8 2021
Sb.Latitude and longitude in degrees/rninutes/seconda or decimal degrees: j
(ifwel Veld,one IalRong is sufficient} 22.Certii'mation ��•,^ r.y:.•
o „ o In;.::xx-•.-a t 12 i
G �St zlt o lZ U 1 2� �t.� ...�,1 �J r}/.'.-:- :!:-..: ...�
6.Is(arc)the wel(s) ermanent or LoTemporary Signature of ed)Yell oatrstar Date
By signing this jams,I hereby cerr j j that the tral/(s)was Or em)constmaed in accordance
7.➢s this a repair to an erisfdeg well: DYes or et< with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Welt Construction Srandanls and that a •
phis is a repair.fill anthrrowu well construction information and expkin the nature of the COPY°fulls rarnrd has been provided ra the well omna,
1.
repair under 421 remarla•section or an the becicofthis form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1.GW I is needed Indicate TOTAL NUMBER of wells construction details. You may allo attach additional pages if necessary.
drilled:
SU$tiu1TAL IPISTRi,1CITOpIa
9.Total well depth below land surface: - (ft.) 24a.,For All Wells: Submit this form within 30 days of completion of well
For multiple wells listen depths ifdffferent(example-3©200'and 2 a@100') construction to the foliowing
10.Static water level below top of casing: %i) (fL) Division of Water Resources,Information Processing Unit,
!Paster level Is above casing.use' " 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: b (iu.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
• 12.Well construction method: rOkor 1 kki r
above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary.cable,direst push,etc) t' construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a Yield(gpm) `1 Method of test: Cfa f-.i..' --'-ve. 24c For Water Supply&Injection Wells: In addition to sending the form to
a/ the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: K j Aa 6i,-, A.motmk 1G completion of well construction to the county health department of the county
where constructed.
Farm GW.I North Carolina Depaammt oflnvimnmental Quality-Division of Water Resources Revised 2-22 2016