GW1--00778_Well Construction - GW1_20240131

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WELL•CONSTRUCTION RECORD(GW-U For inhatIM1.14e Only:
1.Well Contactor Information:
David Seidler _ . •
11.WATER ZONIS -,. ; .
PROM TO- DESCRITEMS -
Wall Contractor Nome
4594-A 41014 4/i ft' (2 Y../: &Pi (Frock/no),
• • - , ft. it. 1 :
NC Weil ContractorCdtilleationftuniber
LS:WIWI WING(far nniiiirmseleliLIFINft intaormo
Aqua:Drill.Inc. FROM- -TO - DIATETIOF • Tormauss MATERIAL
. . .
Company Nand - .O ft' •(p.I ft' G..91. IL liAgi gur
Maria CRS=OR VBIIFEHETOOOTRITI dOlediaMO
3.Wdi Condit-Milan Permft#: 3211(Q. - - ,FROM - •TO-- DIAMETER- - TREED= MAMMAL
List all appfleable wit 1 eonsbuettan perm&fte.WC County.gm%**Dim au%) ft. ' .hi.
3.Well Gm(deck well tfte):, ft: " ft. , IL.
Water Supply Welle . 0.SOW= , •
FR= - To main= Mare=_ TillaDIREF MATISIAL
ill Agricultural 1:4Imcpal/Publio ft. -ft. in.
'II'Geothermal(Ifeating/Cooling Supply) ORtaidantIal water Supply(single) ft. ft. in.,
I,Industrial/Communist Dftesidential Water Supply(shated) ..ie.
- kdaation, .... . ;Moat TO MATERIAL nstruclenurr merman&Ammer
Non.Water Supply Welk ' 0 'ft': ft._ "R"pannirto _fPiJur Cilt4 14yr)rr.rie
di 1 otitoring Inalccovely R. ft.
era=Well:
•Recharge ft. ft.
1111 , ifer InCiroundwater&mediation
19.11ANDIGRAVEL PACK smaisabls)
'A. ., 1-,Storage and Recovery DStrmily&ails' F .ROM TO MATERIAL- - . IIMPLACEMORT METHOD a
it Aquitirlest Dfitomrdater/lisinige - it. IT.. • .
Technology 0SubsidenckfilMtrol • • ft., , ft.
. •
Ai Geodtezmal(Closed 40p) OTracer 20
- - - - -
.11RELING LoOttattedi stIMEoul Owls fissanurv) •- - •
al Geothermal meatinecodiniactuno nohow ottpuin under waRcinuthao eon 'MI BEICRIPTION OFD%broom FolDrireR Imam%aDoi sOO-•"
n ft. g0 IL' ChTtlf_
4.Date Well(i)&amide& I..22..Qii Weil IDS ao ft. fr6. ft• PI sof-045'00 -
sa.Well Landow .SC0 it. Co% M 14i g CiffTvOslf N
-
fe_ 1
gro qtrlei 1.4noth.ms, . . G,i _.ft• 56t;
Radlity/OwnsiNcd PkilityM6(if applicable) ft, ft. [::7. .7 K—..F-7;-:;'4!f 7-'-'
16g6 V.Yin 140 Itinrwr, rs)i 1-ing:soni MC.076.Q4 it. ft. ,
•
PlukalAddramclis mini . ft. it. ' ,,•-•._ -4..--/Al\j-3 1 2104
Slyit-ips . . , I . T,,s---`.f.F.n, Prs-„%_.-.!-,7'
*Corm Parcel ledgliication No.(PIN) - •- - - - - C..".Vw..,‘
Th.Latitude and longitude Ea degneskoinutesheconda or deelmaldegmes: ,
Orwell Add,ova Wong is aufedent) 22'.Certification:
:70 i g.4". N___ egagrlie'Le RV (DI. .e481‘..„,_ I
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6.Igare)thewell(1)tr, ' , ,, neat 'cr.bTemporary Signature fCertifice Nell Contractor Dato
• Re signing Mfr./ben,I kerellp wee tht the wll0)e cc;&ere),eseitritetiyi in aeciwiltiere
7.Is thisa repair to em existing weds ,DIfia Sr a 4(0 with 114 MAC 0,2C.0100 or MA NOW MC.020 Well Conshvatei Stioiderds owl that a
PM te a mkt fill out bassi we comma:Mon bronsition and egpfain tk nanny qftkr coPY eye rectal lun EgenPvukki to e.teiFell&NA
rap:render 1021 sem*masa or en The hoe t qfthis Ann. .
23.Sile disgracer additional will MOE
S.Par Geopeoheipl.p or cosed.Leop Geothermal Wens knew the same YOU now UFO the beck of this peg°to provide additional well site details or well
=situation.only 1 GWal is needed.Indicate TCYfAL NUMBER-dwells conetructionditedk.You may also attach additionsd mil ifnecassary.
drilled: --,-1"i.,-.. ,•
fillEIWITTAI.INNTRECFIONS !,
9.Tel:dwell depth below land=du* 565 • -- - Oa 24s.ardigibligt Submit this Iihrm'within 30 dap of comii'*fetfijrciOvell For=lapis wella hi ill dope's Mout(enntple4MIXP and WOO) COIDITUCIITO tote&doting . . ,
10.Stade water level bebsw top of cuing: Le (IL) Division of Water Resources,Information Procendag Unit, .
&rater level ft abeve easing="+"
1617 Mall Service Clink%Raleigh.NC 676994617
IL Borehole diameters 5 ,OA
241b.Egragba1ogjyglig In addithni to sending the form tothe address in 24a
above,else submit one copy of thin Rum within 30 days ofiamnilition'ef well'
12.Well construed=indhods tanteV 11:
conennaticm to the Mowing 1, ,
Oa.&Men rote%cab%dreat pub,eh)
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. liltelalon of Water Rama,lindavound Median Control Program,
Mk WA SUPPLY WELLS ONLY: 1616 Nall Service Center.ReleigbalC 27109.163d .
138.1tleld(gpio) e9'42 mouttof tau Ceike.:nAillme() 2.1r.For Water ftengle•er linleition_Welk: In addition tO sending theform to
the ideal:(ee)above,also submit one copy of this tam within 30 days of
•Mt.likinfection type: 1-1n4 '71°in Amnon- it.e.z. isompletkm Of Well cindirtiction tri thir county health depatunent of the county
where constructed.
Form OW-1 NonliCsmIleaDtpartneni-oflinvironmantslQuality-DivisionofWater Remixes Ittnrisee 2424016
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