GW1-2021-00289_Well Construction - GW1_20210127

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WELL CONSTRUCTION RECORD(GW-1) For lM mal Use OW.
1.Well Contractor Informadon:
Gary.Thompson 1 wATFRZONSS .:
FROtit TO: D&SCan'l N
Well ComracrorName l ft. -:_a ft �,r
441&A & %
YC lvon Coee4natarCeetiSeetiont!tirm6c 15 OUM CASING al�tf asedwells OR LMB& "'nmNe.
Aqua Drill, Inc. . �_ TD D '' MA
& ft G„zs in. y r1 �v• eo�y
Company Name
f� 16:INN>;R CASffVG OR-TtTBING dos�a
2.Well Construction Permit#: le 'N Z(7 FROM I To I Dlaa>srBL I TIRCHI S I MATERIAL
I&t all opplkabfa uva cmuir=don permfts"tilt Camry.Stare Vortanm err,) ft fL In.
3 Well Use(check well use): in.
Water Supply We11: 1Vbj3tZEN:: ;,:......'. r.:'., :: ::: :'. ::...._ .•:::
FROM To I D14MEnR I SLOrSEM
Agricultural E3M icipaUPubtic ft % tn.
Grothermol(HeatinglCooling Supply) lethal Water Supply(single) it. &
Industrial/Commercial 131tesidential Water Supply(shared) 111.GROUT.,.
Irri lion FROM AlATERM t7nPLA hlEift0
5
&AattI7
Non--Water Supply Well:. Zj R Z% ,;,} ', '
00
Monitoring Recovery ft tt
mlectioa
ft: ft.
AgiliferRechatge DGroundwattxRemediation
quifer Storageand Recovery Salinity Barrier OSMANDIGRAOVELPACB
Aquifer Test OStormwaterDrainage tt &
Experimental Technology [3Subsidence Control tt It
Geothermal(Closed Loop) Tracer 2t►.DBII.LING LOG additional abeeb if
Geathennal(HestinglCooling Return) . Other( lain under#21 Remarks FROM To asscamfrtorr source ere:
fe rT VGA
4.Date Well(s)Completed: l a.-3l-�.a Well IDd fL
So.well Location: A 1- R' Grx►�.: c •
t-Ari`eN ar ernes YZ it it Gros,:4 e-
Fnelityll)vmerNeme 'Facility IDI(ifopptimble) ft ft
Ax—
Ptgrsicd Address.tarty.andZip -y f1Ah�a •`e1C� �J� y ft ft J A
2L P 04ARKS
Catmty P=1Identification No.(PiN)
5b.Latitude and longitude in degrees/mInutes/seronds or decimal degrees:
(ifwall field.one tor4m is adlicdeat) 2L Cerdllcatimc.
6.Is(am)the well(s)Qet naaent or DTempotary Signateae of ed Well atraetor Dare
By siF ft th►s fon,I hereby certify the the well(s)uns fi—)omctoro vd in amordara
7.Is this a repair to an existing well: QYeS or 13No rrith ISA NCAC 02C.0100 or ISANCACO2C.0200 WeNComowden&&dank and that a
((this O a repalrfiUautlaroertr srellcvrwrudion Mjomratan anderpda/n'theaaaae ojdre ropyoftldr rerordhasbeen praldalto the ndl omra
repair wider d21 reamr! skean Oran the backof d*fornL 23.Site diagram or additional well details
8.For GeoprobtdDPT or Closed-Loop Geothermal Wells having the same You may use the hack of this page to provide additional well site details or well
construction,only 1.OW-1 is needed. Indicate TOTAL NUMBIBt of wells construction details You may also each additional pages ifnecessa0 .
dulled: SUBMITTAL IA'STRUCTIONS
9.Total well depth below toad surface: 24n.For All Wells: Submit this fbmi within 30 days of completion of well
For multiple Welk Itd all depda fdifetrrrt(arampl�®2W'and 2(d11001 construction to the following:
la Static water level below top of casing: �-� (ft) Division of Water Resources,Information Processing Unit,
Ifuvier level is above erring.use^-' 1617 i Iali Service Center,Raleigh,NC 2769M617
1L Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this from within 30.days of completion of well
( Well construction method: /o f b'L/ �'� construction to the following:
ie 9n1l�rotary.cable.doeet posh.eta
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 2709-1636
-L3a.Yield(gpm) Method of test:�,oEe 1,�s��"'�'- 24c.Far Water Snnnty&Infection Welter In addition to.sending the form to
a the address(es) above, also submit one copy of this form within 30 days of
.13b.Disinfection type: uk7 a� Amount: completion of well construction to the county health department of the county
where constructed.
Form GW 1 Noah Carolina Depm moot ofEavironmemol Quality-Division oftVater Resources Revised 2 Tt 2016