GW1--00538_Well Construction - GW1_20240118

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4'
I. Pant Farm
WELL CONSTRUMION RECORD,(GW-111 For Internal Dee Only:
1.Well Contractor Infbrandion:
David Belcher
IL WAIVE Mend .
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WontomramorNaus TROMI TO tiECCIUPTION I. 1 .
4894-A 3.2n ft' 3,Q1 _n' I 14/4 a-6-14i il-A• tre Wril CustrooterCentitration Norther 590.fr' .59c2 re• Li 61)Iie F.ra' rturA
It&OUTERCASING ffor zadletemod mar LOMA Of NNA
Aqua Drill.Inc. NWT/ -TO CLOW= Thi(INTIS IT IATIRIAL
•COnpiny Nino O Rs `4-An ,_____•6,96 Lai ei7ii,91 1-le
IA RCM CASING OIL ruenc0 Mottbormol dorodicoon
2.Well Constriation Permit#1: ,Q(12gli S MOM _.: 'TO. MAMMA" "THICINCO1 tylvizRIAL
Ids t at 1 041c4b1cwaticantimetion pawns OA 1114 co ,Sam Voris:x4. 'N ft'A) IL
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3.3.1'.4.,11500-9i.Well ifte): ft. rt. .in.
WaterSupply Well: ' 17.INNOIEN ,..:
' room ro mum= u.or ran rourstorm mama
111 ApiGultutal , CIMunktipsVPublio • ft. •It. In.
X Geothermal Oleating/Citoling Supply) DReddential Water Supply(single) ft. it: la '
.M,.. Commercial DR4sidential Water Suiii4(,hm) _
Iniustian °. MON ro. - NATINOAL voLitualENT Mon=04 ADAM,
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Non-Water Supply Well: -
-• ' O it It' lerimni4e Zur Ckrips 01-14sArge
IP Monitoring _ bRecovezy ft. ft. -
sedan Well: w . .
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X .., Recharge 13Gronndwater Remediation
ft.
1.0521CIIRAVIS Et.
.POcKnramilloortot
II ,I i•-• Storage mul Recovery Omani*Burk r
s TO: PATECIAL. • moremnamor ammo
M. ., z-, Test Dintrmwater Drainage it. ft.
111 :,-'• -,. Technology Dllubsidence Motto' • rt. it. . , • ,
, -IM Geothermal(Closed Loop) Dilaser a&DRILLING&OM(snub titittoniermi illoomoorm . !
In Tlardhennal(fecith4Cooling Rona), ,ricitkor(ex)kinuodor ni Ramada) =OM TO ,-ANt:ftirliOn(coon wawa eawroomo.mei ono om
R. .5 IL f-ON S;•srrAi Sill 1
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4...Dote We Completed: 1,(1414 warn§ . - 5 n' RO th lido 641Ap
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-Sii.Well1Lpeadon; . ft. L
14pn 1A0Vhor . . , ft. ft. . ._ n•:::6*-'':---:•,:-;!\1 iti;
Foollity/OtmorNamo ParilltylDe(Moth:able) R. .it.
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(35q1! hal Intr.lciry4 1 ) ktS.St1IIIPI AJC.0"elPS • .ft. ft. JAM I 6
PhYskilAdthe%Cily.mul Ey ' It. ft. • ,
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'Irr-"o07.17-1 ta. r,
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ror4 44 h 5444.3G-111 . 211.IMAM " _ -
Campy Or Pared Idenlifientkes No.(PIN)---'. - :
db.Latitude and longitude todegoneohnkritattheeanda or dedmal degreem
(Irwellitold,ono Wanes sufff pleat)
22.Certification:i
• 36.6 -si idm.7„ .
w fp° gOt Li i.a" .. w 05,gie 1.5'• OL1
G.hi(ore).69Weil(itiPermaneat or DTemporery Signature of Catlfied Well Contactor Data
By algning,thls Am!havelfp cere that thf.of44 was 0E4 coneueled to affrordance
•:7.Is this a repair to on misting went [Dim or Mt, with Mt NCAC 02C.0100 ortIANCAC OW IOW Well Contnrettan Stands*cad that a
Ugh if aleph;Al 1 out bow we 1 I comslartIon Wan:talon and explain&Move& 1:410'eats rectal ku han Mead 0 geli911 man
-, repalrunder#2I marls swan or as&hark qftld Om
23.fate diagram or additional Well delallu
8.For GeoitraheMPT or Cloud-Loop Geothermal Went holy the same 1621 may use lb bi°k°f this PP to provide"ditimud well aloe detail°or well
construction.only 1 OW-1 fa needed. Indthate TOTAL NUhIBER often" construction details.Yon may also attach adthtional pages if namtaty. '
drffieth
DIISIVUTI`AL INSTRIMCITONS
it Total Weil depth Now luta Milken 7c)5 _ 00 24a.For All'Wells' Submit We form within 30 days of completion awe .
For=WA web ilst ell fcils rained(=wk.36700'eatd40100) cimeatiction tothe thllowing: 1 :
10.Shahs water level below top of casing: '40 04 DIviiion of Water Retbuisee,Information Promising Unit,
&We tr Isfel Is above caing;tas
1617.1We Service Center,Neleigb,NC 2709467 •
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11.Borehole dfammort en _ (1m)
24b.FIT Tibet=Wells In addition'to madly the fans to the address In 24a
12.Well construction methods ignioecy it r above,alio submit one copy of this firm within 30 days of completion of well.
Oh to the it:Hawing:
041.augers Mon cable.elect inaboo04
" INvision dWatarRefearca,Underground I:dee:ton Control Pragm,
FON WATER SUPPLY WELLS ONLY: 1636 AM Servkx Centir,Itikigh.NC 276904638 -
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13L Yle1011110 A Method of test:Ca4th+Tiolp 24c.For Water&mew&Inlectfon Worm In addition to lending the'fbrm to
the addreasies)above,also submit one copy of this fbrm,within 30 days of
13b.Didolootton Ow i•tn.1 70% Amount: leock. completion of well conetruction to,the,county healthdepart:mat of the county
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whore constructed.
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Fool:1W Not&Cirolltarterattournt of Envitonmental Quality,Division of straw Resource' WNW 2424016
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