GW1--01827_Well Construction - GW1_20240322

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Print Form WELL:CONSTRUCTION RECORD(GW i): For Internal Use Only:- " - I` -
1:Waft Contiaetoilinformation:: '
Gary Thompson. - •
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tahorNeam: FRDM To n oN.
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NC Weil ContiectorCettiticatloitMOO •
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Aqua Dr�l.Inc, •• •IS.OUTRRCASI NG(rbrtoulit ,edi )ORI4IIVERMs le) • -
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•vnoM TO• DIAME=. THIc ons•.-�'- MATERIAL
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• . :IS.INNER CASING OI TLIDnvGYeeotbtamt
'2.WellConstidelfonPermit#:.- • )
oppliaabke Unia n numeral
ibtiYaU Pula(la•ulG.Caml sYala vatara4 erc) -t6• � • i la..
�'s� MATERIAL. .
3:Well Use(swell use):• sti 1ti In.
WaterE.m.,h,W.H;. , 11.SCREeN
• CnlhIIal . - l��: FROM - TO. DIAMETER,. SLUTgl� •TRICalEdB • MATERIAL icipaUPoblic • ti' ft..
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Geohemiel(Heati Cooling Supply) •1�' !7' : 'WaterSupply(singie)
InduoiialfC • • - : DResidentiat Nikki snpply(sha>ed) • -
• • ltl d'RODT •Initiation . . . . ' FROM •- To - stAtinuet,: • Ea!lLAC6stitiv surrnDnetmerouni•Non=Wmr.Supply Well •M, - - . : •,t> -zip $•• a vrIaab.'Fc-
• • . . ®�� ft... .' ' ft. - 'Cti ps, . 1 •ate~ M' C."
Killen`Well• f
Aq' •dtferRe ihatge
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QuifecStmageandRecovay: - • .1!SANAAGRAVELPACKttrapRI bL) -
�ioin tyBanier " snout - TO -' - MATERIAL . •>zalTtitcsi+inirtturreon.
AquifarT DStormwaterDiai a• ft Q,
Eipe:imaatel.Teahnology. ElSobsidenceiCtmtml R
G4!then11a1(Clmed Loop) •Enna . . 16.DRQiwC LOG(itEaehaBiaiooalsbeb lineman) ;
. Geothermal(Retttiop/CeoliegRehim)•. fOt er(explainunder#21 Reinedo:j• Faoal. , . .TO naacRWUONtman RaristemaivincRi tutlyd i,,z e.)
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4.DmeWdl(0).Qompleted: - y IL{ ::id 1Dii R. it• i ' •-
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Ploi il,AddRry City,eadzzP • . :it:: - - R; : a �A r,‘w1
�ITI? G 21.RE<idARl�" .:a a K , a .
. -. . .:_PaaeiItldttlf tIGSNO.(P41)• • MAR .2 _;112d
5b.'Latltade and iongtliTde In'deETr:ea/iddDtealtteceuds or detdmil degneesa
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•pried tie1d,on lttllongiesotHcIint) . -
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+ a' �' ?,'ll, 1��°j5 :22:Certlg oust: •G ,Q ;, ' i:r^:
5,18044 the wells) eimaaent or'DTin nosey - - : s"' o c1um143v,c tractor' . - 'I?*
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7:Is this t Foie!to tlD �� :By.alenb.P this forrs,.I heieby that at.w dift)Es( +J'oonruuekd bf'aaeardanoe.ealtiting wade 'Dyes•or 1iQIt - • with ISANCAc oaC:0180 or.ISANCAC 02c:0200 Well Conrbuetfav�,Stoadardrand Mato
.Ijakisaepairfillorabrown well consb+idionhifcvmationanderylainihiawareafil . �PyoJ rmoriihasbrenpreWdedmtheiallmtea: •repOriiatier021rnmalfa: oian the bachnit ttfoma•
&Fro P 2,1 Shia dkgrrim or atititional Tlsell detallx% . -
GeepmhelDPT or Cloned-Loci Geothermal Welld'havingtitesame ' You may use-the-back of this Pig*19'provide.eddition-al well else devils or well: •
conshdctitm4:on1yI13W-l"is needed.Indicate TOTALNUIV1BERefwells • . . conettuaroadt!ails.-You PAY also>itlachadditttonalpegesif W#SS26
Sp>jMtriTAL INSTRUCTIONS '
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•9: e Totilwelldelith ilk*laidlaids�c�� �[J� . . (it.).-. � .
- Per*deestdklistaUdepthslfd((fwentl e-3©7oo•mrd2@lp� Z4a.For All following:
•Sabmg tLie fiirm withfn 30 days of completion of well— .
. t onsttuctimi.to th following:
•• 10'StatIc water level below tap of easing �✓,7)-. .. •
••lf, level In above eattng�e � . . J (R) D1vLion ai Watet Reeoa�w,Information Pnimensing
. • if17 Mail Seriice Ceuta• Ui(fy,
1L Borehole tRanieteis • .f-9:
iNC 276994617
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24b:loam Illeglon Weft'In addition tn.sending the form to the address in 24a •
12.Wel1 tasrishaetloa;lDtdhod: 4 re:r tq:►`f -shim,:oho submit ode copy of this-fomr within 30 days;of completian:of Well
( wee*.fir:aablo.dk eetttcmh,ern) [. - construction to•the.-IIotvinp:
'' -. FOR WATER SUP1rLY Vl►ELLS ONLY: -
_ Dielsion ofwater.R somrea;Undes annd:Injection Control Program.
y • 1636 Mail service Center,Relilgb,NC 27699-1636
..13#•T d it, . . Method oft sh C ts4J' 4rti k t,: 24e.For Wa erSttonly&"
- I;• �- � 'A. � �3 .�'" IajeeHi►m wellae ra addition to sataiog the foim to
13b.D1;. cltoD•typ. . .� 1- • 7u/P Aiaot.,. J6". _ . . the.dddress(es).above, also!Abmit'one copy of this:theta within.30 days'of.
�. t. - completion Of well comtraaron to die county heath-dcpaitment of the-county
wham aagtteticted.
FarmOW.l.- •NasthQoioTwDap troPEavltonmeanl D
z Q�114Y- .liith aoPWatorReaotnca Revispi2-22-Z016