GW1--06613_Well Construction - GW1_20231017

--Ci�laYltUrt;YY+it�iy ttECUI `{ yV it— -- — nt'Form
y q, For Totems Use Only,
Contractor Information:
Cameron Bazin •
lam t 14.WATER ZONES
4518-A � 'v Dasca�txon
NCweft CamaetorCetr6ratianxomiter H. n:
Aqua Dill,Inc. S.AVJ71l1CA.SIIVG farmnitE�ared ORLIIvR d "
• T'0 ° TtDciavt� t�tATecerAL oavxttae • ,� ,73 !1i ,_
• a.W.aCo aSonrereart ( • /PINHRC�vGOR TUBING(Searcrm lcl .le o) r"V
i.trtall applicable tall cansharttaa p (La WC Cara . FROM D SlAT6RUaL
srata Yo►9mroa eta) tw tE ta.
.wen Use(check wen use):
Ater supply Well:
17.SCREEN
•cultntul
OM+mUCipalYPablie FROM To DIMIR ER : CLOTURE MUCHNESS MATERIAL
1 Geothamnl aleating/Ceeri en Supply) ft. ft.. to.
industrial!' Co Commercial
Water Supgdy(shtgie) $
Residential Water ffi la.
Alai oa °�( 18.GRODT
on-water Supply Wen: SROM To • MnTenrAL re,rr,,tcsMExrME oD&AMOVNT
1Ma.' . O it' -23 it' al,Injection Wen: RecoveryiS ft.
II Aquifer Recharge E3Gr6uadwaterRemesdietion ft. R.
I.•quiferStomge and l iy 19 SAND/GRAVEL PACK(S!aopiicable) •
Aquifer �.SaljaityBatzier FROM �
AquiferTest mATERTAL !MrLACEM&STMEI1IOD
D5to
illi ->'.ctimtmml Technology �waterD Drainage ft. ft._ m etml(Closed Loop) CirriaCer�S° ace Central a . . .
Geotherm •al 2O DRILL=LOG&Rubadditias als�etsKzr
lia=Raton Other(-, tsiannders2l Rematlm FROM TO D�.ammonWa,�,m�,wnnoeke�,ae,yuoa�esa)
4.DaateWef(s)Completed: 42125 Well IDS . Ai 47 �5-e--
sO.Well Lnmtton: ( ?$1� ems.�l�
FacilitrawnerN Facility Dj O(INPlitabte) ff. p�
�. 1/At/�j/ rr 1`�'_"' �arpjl ft. A' 'F ^`$.. r' `f;'• n i
PhyslcalAddress,Csty,aadTep I ft. or.r �n„z
4,-)00 (cl✓
.45,6. . � 21.REMARKS _� .
C b' • Pateel Identfettroallo.(PIN) i n �; 7 ;a '
ii`':i
Sb.Latitude and longitude in degreesindoutes/nacoads Or decimal degrees: :,• L'i3
C well field,am bslbnp is aufficiem) -
. `�8('J$ z. . 22.Certification:
6. s(are)the well(s) Permanent. or }Temporary Sig tractor
to an/� �t��y1 BY �f ni,.I�Y ecfl .that the sills)sue(�vae)constructed fa amerce
•
7. this a repatranthto existing
eanttrucdfa�n Y or K lainPanahaeo the !0'l mend hm 6rO orMI N=02C.0200 Well Constnrctiar Standards and that a
If itot+epalrfill W create f av o Paavid�tothexrilam=
rr i #21 reumlt,section oroa tlrebaekoftliisJonn. 23.site diagram or additions'endl detell
S.I or Geop ohNDPT or Closed-LOop Geot ermal Wells the same t on details.Yon may=lb:back of*Ls page to provide additional pages t site 1s or w•
Gijon,only 1 GW-l'is needed.Indicate TOTAL NUMBER of wellsIRIBMITTALINTRUCTIONS
may eta*
• ed
9 well depth below laud surface: S ( ) 2ta for All welts: Submit this tbma within 30 jr muWpfessvdlslistaildeptlirfl C o-3@ZDD mtd2®It1Dq construction to the following; • of.completion of well
10.Stade water level below top of easing: 5� (ti:) Divldon of Water Res®uraem,information
IJt ferdrsalimea*g me«+'
li17 Adil!Service Center,Raleigh,NC 2769iq fit'
11. hole drueter: 'l �(rn.) a4fG ot�Inlee nn�1Yeps: TD addition to
(b, above,also submit one copy of this foam suntruiwithin 30 fozm thO s in 24a
•
IZ. el)cons oa method:
/ construction to the fallowing �Ya completion.of atell
lame saga:Mary,cable,O URA.area
D3tdsron of Waterfesomn ,II
F WATER SUPPLY WELLS ONLY: iq6 Milt Scrtidee C �Ileahloa C°afrol Pt o
n °°b4fs Ralelglt,NC 276A9-16 �iO,
13 Yield(gm) 20 Method dint 7/�4� � a)si6tD�DIv I� w.n., lA addition to '
/� one
l�tam8 thn f
13 .DlsinfeeHon type 6 '` Amount L��i completion of well oonafaetron to the o w►t1>o1 30 to
whereaonstructed. �'��ds�ettMent of the��
._ ,
nes
Fa GW-1 NanhmmltoaDe�t tofBnvhonmontalQmlrly-Dh+ldonofWttsrReraa