GW1--00210_Well Construction - GW1_20231229

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WELL CO T�tjgan®1V)<3Ea�>a�.y� a its Pr1ntForm
IL Well Contractor Information:• or Fate se o y:
David Belcherá -E
wallconhacta;Name 4594-A ■t m CAiP CN
mimlNC Well ConhaotorCetfit[cationNumhar `
Aqua Drill,Inc. I9.OWED CASt®mtl.arga�oRLIIVER '.,
CompanyNatne IlUaimi r® D7AMEYEtt -
nstrucdorr Eye " llaIII
d: � ,i
dice rmit#:�Eif �c�es,� � ,,.tea,.,MjIIIMIIIIIM�• �
ListWell
ell pConst a well co Permit 0:rants t1 UIC,County, '1. r0 o;,,
State,/Bairn e.etcj tM, ! r i�i y �, "' 1 8lA11.
111111
&Well Use(chockyreY9 use):
!!Valet'Supply Went lit ; ith
3giAgricultutal
, 'aipal/Publio o u 21 r r t ± ia z, N yam, mur aunt,
Geothermal(IIeating/Coaling Supply) .Il Residential Water '
)r'Indushiel/ConmlerclalPP(Y(single)
*Zvi rcri_:Lion •
Residential Water 3uPP(V(shared) iB cRotfa ®
Non-Water Supply Well: ' ---_ . --.. --- . . ._ moti�.MA1 OU4. PM'LACE ME TME/ROD&AMonNy
"Monitoring _; Recovery •:
ft. fto ('r,
MEM
■Atiuitbr Recharge Fri Groundwater Remediation
• `>it&AterStorageondRecovery
`rlSalinity Barrier t.{;: vE[.PitC. lie„Ice_
"Aquifer Test braking stroll,Q 're EMMA.,9- > . .
lit P�m►mttelTechnology 0Stormwater
Subsidence Control - fi°
If)tkothannal(ClosedLoop) Ai;hour
IWrGootheanal Coon:Return) *Other v. � MIDRiLLINGLOG ettichadomanet:,• ,
,leinuada#21R Q oss "`a
®� carry Ol COtOT_L!!'gall/rack /...:. :L la ate.
el.Date iVell 0 tOMNI Or, '
()lromrpleted• f •r)' Well!®# 11
Sa•Well Locaton: ��t.
. Faclhty/OtanerName
FacSltyID#(tfepplitublo) ft. ft, ,:: -,s_ - _ _ _
PhysitalAddres.City.and My --
County /f t 2
0
$4 ..... as.SER9ltdS
ParcelIdcnttticetionNo.(P1111) x s:,:::
r.,-:! tits i
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96.8,gtiti dear.,lougih:de ha degreeelalrllites/seeonde or dug,i !degrees: .- i •
Orwell Heidi one!anions iseatSalen9
•
.JE(aPe)�i!well(s)•. Permanent or D�'@OZJyOra�y Signature of certified Wall Contractor � �
!d
Date
2 la this m repaEe to an edging well: �9fet; or By signing this)bnn,I hereby certify that the wells)was(were)eontingtad in accordance
I7.l a t id vepa pa rttd lerpnsr tmg welvuglon ® with lSANCAC 02C.0100 or ISANCACO2C:0200 Well Construction Standards and thata
ltlfoaeaatlonandexpiain Me edam of the e0P3'oflhisrecmdfras hew providedtrrthe wall owner.
• 'repairisinadrepa l s�mldlato n wellor eo mete l e ofthis form,
S.For t"seo 33.Site diagram oe additional we'details:
Pt o&e/D "d'or Ctoeed-Loop tGeotlaetmel Wells having the same You may use the back of this page to provide additional well site details or well
construodon,only 1 OW-t is needed. Indicate TOTAL NUMBER ofwelts conshuction details. You may also attach additional pages ifnecessaryy,
drilled:'
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9.`1'otalwe➢fl g' ;:,..• ' •'itg.�$RII£'1auct.°1'orm I
a4ep41t below lead surfaces ( j i!
FormalliplewaEastal1depths{�d/ van( �•300D'and2QI003 ( ) Vim.Fop We Submit this fopm within 30 days of completion of well
construction tithe follovd,,W 1
IL Static Water level below top of=slug: GO
Ifnw(er!svel to cbaveomsbel usetop
(ft.) Dividou of Water Resdurc s,IInformallon Processing Unit,
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IL�orabnle diameters �,� a 7 PAH Service Centers 1�lo�t,RIC 276994617
(Igo2eb.yor reilestion Wells: In addition to sending the form to the address in 24a
IlB.Well sonshrao9lom mod: 11 i1 r� /�. above,also submit one copy of this form within 30 days of completion of wall'
d°'a" ,may cable,Crate push,etc.) construction tote following: i
8+®1a WATER SUPPLY WELLS ONLY: --_, 'derision Resources,Un,-rr.1i:,wad Injection Congrel Frogeatm
MS RQallSelrvice Center,itetielt ,RlC 39699,Il636
IJm.Mehl(ggBp6a) ��( Method enrol: � j
d 11fpe Vie°►fa a An hole 4 , ➢files IA addition to sending She fern to
83h.TDlsittfeetl®a c,, a: NI i-!tj(Jo`� the addresses)abode, also submit oho copy of this form within 30 days of
�uut: I( c z completion of well construction to the county health department of the county
, where conshtsoted.
Form GW 1 North Carolina Department efB6Vir011PIA0nl0I Ought-Division mFlNatesReim. .._>__ .....,r.�