GW1--00163_Well Construction - GW1_20231229

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I.Wit COniractorllnformation:
David Belcher -- . _ i
WollContractorName 14.WATER ZONEs I I
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DESCRIPTION
•4594- gad' e9,552° Crfir_L ercar•itrre)
N0 Well Contactor Certification Nombar fr.
Aqua Drili,Ina. -lg.MITER ANINO(for mulikuseawells OR LINER Of on eable)
DIA41w'en TAlCa1 ss MATERIALCompany Nance l g' 1 Co i ft-I Cn.a.11)DL s�1R. i_ 'Pi'
�.WeI1Co11aQluctlonPsrmitt y� IRNERCASINOORWRUNG(aeotheivasl ••I-,doon)
! Coop, . , FROM DIAMETER .4 i g MATERIAL
List al aPPiicabk well aoirstrucrlanpermita(Le,111C,Coua .State Varlanc etc. C. ft. lo.
3 Wmll Use(died(well use): 'ft.. ft. I. ;to•
.
Water Supply Well:
Agricultural FROM To DIAMESSR' SLO t= TRIMNESS .MATERIAL
11: =iyfinioipal/Publio R. ft. in..
1 Geothermal(iieatimg/Cooliag Supply) i►.Residential Water Supply(single)
titLtdusrliaUCommercial R. In.
:;r'1rri •,on +Residential Water Supply(shared) ng.cRour
Non-Water Su MOM To MATERIAL EMPLACEMENT METHOD&AMOUNT
pply Well: ct
i11;Monitoring r-aReCovery _ 4 a�, ^►tl: Pour Ci�,PS 1a �lr,
foleetion W :.. ._..-.._._ � - — Pte ft '
ylil.Aquifer Rec}tacge 111(iroundwaterReatediation ft. ft I.
l�Agotfer Storage and Recovery Dsetinity Hairier 19 SANDIGRAVELPACK(il,amstiebble)
at BaOS1.. To MA7ERU1t' FMPLACEMENrItIEIWOID
'AquWcrTest bstom►waterDretrtage t$. -
lft Experimental Technology subsidence Control a. fw
4101Geothennat(Closed Loop) Tracer •20.DEEMING LOS(attach additional shush ifaaeearar9)
•Gaothmm ,. , ,al� � _Co.1,.i Ream , •Other(;+'• :• under#21 Remarks) most - ao _ DESCIUPFLON Won eardnea,7 eowraeteryeaseom.m OA)
Q ft° .;1( ft C lci
4.Date Welt(s)Completed: i 2°i 9° 1 Warn it.
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Se.Well Locating �,(� tut.
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it tP4,�n J1rih'e 3. i fusion 4)i tin gi5tt 'dirt: itrij.13e
Frei /OwnarName FacllltyID#(ifappitiable� I
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skalAddres � l
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�► Address, a. fft. i ' IF C 3 & Lti J _.
kL &L REItdA1� .
County
Powel Identification No.(FIN)
1 '�T' �` 'i
Ob.Latitude and longitude In degrees/ , .;,;tea/aeconds or ahead degrees: - I -
Orwell field,ono.helms is sufficient)
22.Cesttt3eatl®n:
GP pia y I " N S'lrl° 2l r 6g 9'' w✓
Tr/Q:4 mom)GM weli(s) +1Dermaneut ®r °T®lnporary n I! 1 e° U-
SignatoreofCotifiedWellConhactor , Date
7.lia this a repair to an addingwell: °E'es or I r No with signing
2C(MOO or 15A eerie
AC 020.0200 W)wasConsrtrucilon Stands and grata
lfihisisarrepair.JIilonehrwwnweUtoitsiractionigfbrination and expfain the nenofthe eapyefllns lucent has ken Provided tothewelloMer:
repair under#21 remark section or on thehaekofthisfarm, .
S.War Qaeo 23.Site 4106 aria or additional well details:
preleMT or Ciosed-Loop Geothermal Webs having the same You may use the bask of this page to provide additional well site details or well
construetlolt,only I GW-I!is needed, Indicate TOTAL NUMBER ofwelis construction details.;.You may also attach additional pages if necessary drilled:
1IIIMElltld SIT A1�Ts7CYa IUMP rONS 1,
p Total° I .' .th Mow laird surface: ,Q 5!
Far maliipfeweU siist6i(depots(rdt8erent(eratople.d(a3200'arda©yotlti m °) 24s°Y°r Ali Walk Submit this form within 30 days of completion of well
construction to the fhl gt 4 1
fl®.Ste9tewater level below tap,.�;easing: _ � `
lfwatcrknells&weaningerco"4" - QR°) >mldisiataoff WoterYBesoparses,llfta9br®ta0logloaoeesslug�Tnit,
2419 Mats Swim Center`
ill. cgeholle„+•meters (n Raleigh,ld0$96•Jp9Ilt5E7 •
0
fin.) 243bo r n
hurtle In addidoa to sending the norm to the address in 24a
112°Well ccnstvumton methods ° above,also submit ono copy of this form within 30 days of completion of well.(i o.eager,Mon wbto,dlrectpastyme ���� Construction tothe.iollowing: ; ; •
SW WA I itx RIPPLY WE1LII�ONLY: imiv den off Water]gesolls s,Undlerp,roundllnjection Control Mom,
MS Nan Seredca Center,Raleigh,RlC 296994635
1182.TWA(gpm) ,
® ! oeH died:�-ho(3,10:e_� 24c,,rror Walter SaaBDflv&Bnieetion+Walls: In addition to sending die form to
11eb.lDll9ltofee(ton type: }4`rl4 70% the address(es)above.also submit one!copy of this form within 30.days of
Amount: 16e completion of well construction to the county health department of the county
whew constructed.
Form GW 1 North Carolina Dcparfinont of Environmental Quality-Division of Water Resources ,