GW1--03399_Well Construction - GW1_20240610

WE L CONSTRUCTION CORD GW-1
For Internal Use
I.Well Contractor Information: try, — Print Form
David L. Hard , Jr.
Weil Cat�etar Name ta.wA raR ZONES -
2906-A •oht To _
le � � D=fir„
Wallail Contractor Cenificatioa Number e • df
Aqua Drill, Inc, is.o -R CASINO ,.,.
iaont TO OR
REATERME
Co>rFanyBlamDIAMETER-- � --��.'
2.Well Construction 0 Permitq: E: MICA Wrinnall
—
DVIYER CASING OR TUBING thermal-:_
,uYriretion permits Le.U/C,County.Slate Hance. /
3.Well Use(check well use): 41.
— R +T�
Water Supply Well: - is
a Agricultural t©©
°MwieiPa►1Public 6ROht ©R !Err �Vn-
VI Creathermal(Heating/Cooling Supply) Residential Water Supply tZ _ •1 MATERIAL
1.1113111161
I industria!/Commercial PFy(single) inirso _
Residential Water Supply(shared) __
•Wile lion IL GRO
Non-Water Supply Well: Mom ,
Monitoring ��c!k i-• —
I.Recovery � �erG`j r7 .,:., t
Injection Well: Wfirepurgaztra
il 1'Aquifer Recharge _
gtlifer Storage and Recovery OGraundwater Remediation
Salinity Barrier F199. y© efa, able
i Aquifer Test
QSMnnwater Drainage e ©© MATERIAL —_
a Experimental Technology °Subsidence Control
1i Geothermal(Closed Loop)
111111111111111111111
Geothermal OTtacsr
(Heating/Cooling Return) •that(,.lain under#2i 20.DRILLING LOG mach>�t oed bane ie -�_,
Remarks) F"11.111. a .:, , Ni2-mr -. wnhod[.,_ .. -
4.Date Well(s)Completed: 1
l/elf>Dfe � �
Se.Well Location: '�/I L�`i*
Facility
ME 3 r-
svrmrNoma FncBity iDk Cif h ' - <
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app cabin) •-
P �t /� ,y STD aiiiaingii ? 'r \ c'~'�
h$Sllal Address Ciry,and Zip /l r / •.....`/tr t
27/e‘ ©�I
i..cc.w.y.A__ ._...... ...__
21.REMARKSi ) .1:
Parcel identification No.(PIN)
- "-e-ed ellifhe LlRit
Sb.Latitude and longitude in
(if well field,one latllong is sufficient)
or decimal degrees: r
1:, L:i/ ' Nei 371 ''/ w 22 ,caho,
6.Is(are)the weil(s)Cipermanent or ++��..��,, �J i
i �Po�y Si,. . : ofCernfied Well C.,..7 or ---
7.Is this a repair M an existing well: ®Yes or No By signing this ant,I he , .
with ISA NCAC 02C.0100 or ISA NNCAr C 02C.0M0rat the IWe l Co was wl rzem statztucted In accordance
that
If this is a repair,fill ow brown wolf construction!nforme:ten and explain the nitre of the cap,afrhis record Ito,bean provided to the well owmir.
repair under 021 remark*section or on the back ojrhls form. N�tO7' a and that a
23.Site
e.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back oft is or additional well details:
construction,only 1 GW-t is needed. Indicate TOTAL NUMBER of wells page to additional
additional i fn site details or well
drilled: construction details. You may also attach additional pages&necessary-
9.Total well depth SU mom_I,IIVSTRUCTIONS
P below land surface: ` (ft)
Far madple wells/tit all depths if-different(emmple-3 200•and 2Qa 100') �a For Wells Submit this form Within 30
construction to the following: days of completion of well
10.Static water level below top of casing:�,.,�''
!10. ta tol is above casing ran (R•) Division of Water Resources,information Process
11.Borehole diameter. �,)
1617 Man Service Center,Raleigh,NC 27699 617
24b.For Injection Wells: In addition to sending the form to the address in 24a
12 Well construction method i,/^ 4 . above,also submit one copy of this form within 30 days of completion of well
(i.e.cum to •=Me.direct pueb.eta.) construction to the fallowing
FOR WATER SUPPLY WENS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
24e.For Water Sunnty Sr Injection Wells: In addition to sending the form to
of
Disinfection /r / the addresses) above, also submit one cosy of this form within 30
type 7 e Amount: ft completion of well construction to the coup health days county
where constructed. �' department of the county
Revised 2-22-2016
l North Carolina Department ofEnvironmental Quality-Division of Water Resources