GW1--00211_Well Construction - GW1_20231229

•
•
II,t ®I1T��Clt�C'e'raA ld]Et�®����► flDPrint Farm
For'mental Use Only:
1.Well Contractor Information:
David Belcher
Well Contractor Neote 14.WATER ZONES I
Elm
TO DESCRIPTION
4594-A VC) e' 411 a 5(?Pit (' -e.lai ) ,
NC Well Contractor Cedffiestion Number ft. �,
Aqua Driil,Inc. IS.ODDER CASING(for mntti.asanwells)OR LINER Wen cable)
FROM TO DIA87F,TER' THICKNESS Er LIRRIIAL .
ft.ComponyName p — I On.. - I Co.. ��' I _�gI 'Air
2.Well Calittracfl Construction gn �lCz FROr CAe1NGORTi18IIVQ(Ieatbermalclosed ESp)
List all applicable well coustruetion penafts(de.UiC,Coue%,%State,Variance,etej !t. 4L DIAMETER• . MATERIAL .
&Well Use(eheekwall use): R. ft. • in.
Water Supply Well: 17.SCREEN
dNAgiicultutalcp FROM TO- DIAMETER SLOTSIZE THICKNESS. MATERIAL
. .pal/Peblio ft. ft. In.
*Geothermal(ffeating/Cooling Supply) ;I,• Wendel Water Supply(single) Lt. In.11industrial/Commercial Residential Water Supply(shared) '
r i : ••on 1@.OROBfr
NORVt►8tert3u -_.. .__ ._ ... _ FROM TO MATERIAL EmELACEMENTMi:TRODamaw
pply Wells
J Monitoring ._ ORecovery__ � P!) /p;{t� �,t?r (`i�;�Js °t I. r)ict}e
Cation Well: -
Ili AquithrRecharge °GhoundwaterRemediation
18!Agaifer Storage and Recovety �8alirdty eaIIrier IS.sAtamta:11AVEL PACrc(if ocatimMI)
' •• thrTest - TMATERIAL LACEMENTMETROD•
�BtemlwaterDmineg® ft. R.
ii a,•erimentalTechnoiogy ' Substdenee Control • aft. ft. .
11)Geothenn 1(Closed Loop) Tracer 20.DRILLiNG LOG(Mina edditiaaalsloth Duatelsar9)
.rU Geothermal :•.tin_Coo ,_Return) ti Other ,lain under 021 Remarks LIHOal To. . "'WW1!'"(caton etreat9,nuwraexeraamoro,tA area-
•
d.lOateWeIl(®)Conrpleted: ln?'1Si' a?? Wen1p�-- f. CiG
Sa.WeIILoeeHoa � Scan! S�i,i
�7p met- �©fit' 55 ft' fit H 'C.' ;•�W
Salo .Sale . 5.5 fl 3I5 c� 'AIL'S C-r(rmnl4e -- :> . ,_
Facility/Owner Name --
1FacilityMD(irappl:cable) ft. itt. . `:k i,...,,L
Phydeal Address,City,andRip '. �'4'" r` F (t, D. D i. 2 v 2G23 • •
rt1 tl') 2L flMMARid6 rt J - -
County Neelydentifestten No.(PAS C °v ti f ~' t eF N
Latitude and 1tingitude In degavesSMIRRTEAMmadu or Gleclmall,-grew:
Owen field,one ietl(oag is sufficient)
`1,Cn L' I ° 5�.9" •CertitYe®ile®s
N n 1,0' .96.4" w
6.Is{are)thewoli(s) rmanent or Te ar df fi t 0t- 9'
rapt aCy 'Signature Certified , Dam
9 lie this se re . • 8y stake g this Jbnn,l hereby vete that the well(s)-wan(ware)Conatreeled le accasdaaeo •
psi to an ealsting wens Difee or ' �No with ISA NCAC 0IC.0100 or ISA MAC,02C.0200 Well Constwellon Standards and that a
Pals arepabe fill oullalown wellcenstructlou bl(annafon to dexplahn the nature ofthe eopyofthislt'emri has boa provided to 140Ivaownei:
repair under d2l remake seetlan arras the baekg(tbisfami•
22.
8.For Oeoprobe)PT or Closed-Loop Geothermal WeRs having the stone You may uite se diagram
back Cr additional gel oLprovi
construction,only 1(IW 1 is needed, Indicate TOTAL NrJ R°fulls y aalso attach addittionade additional
p a e ifwe details or well
drilled:. conetrtiction details. You may pimam.
Bn1i4MKIN Al.Algt,111Q'AINNIS i' '
9 7fotal<well aiepth below ladd silrFare: �� '
AOentbOewellsEstaffdepths((deant(example4 00'and2(01009 (ft.) Gov Welk. Submit this form within 30 days of completion Of well
construction to the following: ;
19.Stade water level below top of casing: - 5C) ($t)
linter level le above waft two"d•° �-'vittlon off Water]�SOOrCego Information Processing Unit,
11417 Eton Santee Centeav IEZafeigh,ne 276994617 Ill.Roretude diesnetens .fo
Qn`) 24h.Altar linden Wells: In addition to sending the form to the address In 24a
12.Well conatrustlon methods ikkt'V A ' above,also submit one copy of this'themn within 30 days of completion of well Oa GUM rotas,.cable,direct gnat,eta) construction to the tbAosviug: I
FOR WA'i R®111PP8:4f WELLS ONLY; lmlvision of Water l ee®ogees,(ffndeagrommtl In milon Control}f an sea,
1636 its Scram Conter;Naleigh,NC 296994636
flea.Ma(0pse). I/1M lo(B Wed:' (74-l'h 4 `�' ' Water or W ter Sottnly it.rnlectisra Wells: la addition to sen
ding tothe•far�n
•Il96.ID1ehriectloiaH,pe; I-i'CI i�7®dire An the address(es)above, also Submit one copy of this form within 30 days of
.J(ofr4-. __. completion of well construction to the bounty health department of the county
where coneuucted.
1.
Fonmlow-1
_. I, .
I,