GW1-2021-00290_Well Construction - GW1_20210127

WELL CONSTRUCTION RECORD(G%1) For Iatemat USe Only:
L Well Contractor Information:
Gary.Thompson 4.wA TONES
Wall CoumorName FROM 'ro•: D85CWrIUN
4418-A s 1 S 4 fL
r+7Gt o d (O a
tee �
NC We1lCoatmamrCeetifieatiar+NismLer 15:oUTER.t 9-10 fbisniulH�ed3velrs ORLIlNSR
Aqua Drill, Inc. . Mid DIA61rsMM -. �►
-C:> .lob 4"x� ta. tN r'
Company Name• u
Ifi.-INNIRCASINGOR-TUBING . _ d
2.Well Construction Permit* 4 O`7) W eL 'I"a FROM 7o Dlatasret 77IItI4hSS MA
List all applteable hell o nwracdon pemda(Le UJr-Comay.Slot.VaAamvarq ft. ft. fo.
3 Well Use(check well use):
Water Supplywdl:al � PROM
Toft.
DLIMMER amsim a
Agdcultur cipal/Publie fa To
Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft. it In.
rnd ,
ustrial/Cammercid 13ResWential Water Supply( JL GROUT
trri tian FROM AIA7EItIAL: RM ACH1 EW oD�.uhrODNr.
Non-Water Supply Welt:. & 17-1h ft N ti r
Monitoring Recovery & ft
n ection well:
ft: ft.
AquiferRedtarge DGrohmdwaterRemediation '
19 SANDlGRAYBLPACK- a '
quifer Storage and Recovet [3SWWW Barrier FRoiu 70 du7meTAl. MMAMMMMM
Aquifer Test 0Stormwater Drainage M &
Experimental Technology [3Subsidence Control ft ft:
Geothermal(Closed Loop) Tracer 2LDREUMGLOG nddWobd ff
Cleothermai(HeatingfCooling Return) nfter(wtplain under021 Remarks) FRont TO asst'arrnoN(=bm, ivairmimanizingar-ate
ft: I Jr ft.
4.Date Well(s)Completed: 12.Z�"?1> Well EDM f 5- ft: 5-5' fa:
5a.Well Location: R G) R'
Fae+lity/OwnerName Cae7iry lII0(ifapplieabte) ft. &
Pbpkal Add—n City.=Mp R ft
oMID
1#'1'L°r' "t 21:REMARKS
County Parcel raaa$ficmion Na(PIN)
!ice 1,-n 4'Cr'�•n i iJ:n.
5L Latitude and longitude in degr eedrulnutes/seconds or decimal degrees: ;.:�
(ftell field.one b ltong is sufficient) 1J J a • `
22.CPtIficadow.
6.Wore)the Mllwuoermauent or DTC'mpo; S+ of etdfied Well tmcmr Date
By slgnhrg this jam,l hereby eero drat die udffik)um fires)aommwW./n a=n mta
7.Is this a repair to an existing well: 13Yes or o +dth 13A NCAC 02C.O100 or l3A h'GIC 02C.0200 WdICamnnalon&aadan&and dml a
lfddr isa repair,fiUoat hnmm well eonsdacd ln dhenomm ofthe copy ofdds rwwdhas bearpmIdedm do inzll mwer.
mpafraddw#21 re mrhssardon or an the baL*efddsfosm
23.Site diagram or additional well details:
8.For GeoprobeMPT or Hosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
conshuction,only 1.GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecesmy. -
dolled: 5S ji BMITAL INSTRUCTIONS
9.Total well depth below land surface: (fL) 24s.)tor All-Well Submit this form within 30 days of completion of well
Farmtdriple+rclhltstaildepdestidjBerent(e:ampk-3�00'arrd2Ql001 conshnctionto the following:
10.Static water level below top of casing: e-1-6 (ft.) Division of Water Resources,Information Processing Unit,
banter level&above casln&use"_" 1617 Mall Service Center,Raleigh,NC 276991617
IL Borehole diameter. �' Cm•) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t+ bey Air above,also submit one copy of this form within 30 days of completion of well
12 Well construction method:
r construction to the following:
(i e.anger:many.cable,dirmpush,em)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test: e"�t +- "e 24L For Water Suonly&Iniection Welter In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of.
13b.Disinfection a Amount �-Z_ completion of.yell construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEaviromaeaml Quaft-Division ofWater Resomaes Revised 2-22 2016