HomeMy WebLinkAboutGW1-2021-00291_Well Construction - GW1_20210127 �: Prtit�Forri.
WELL CONSTRUCTION RECORD IGW-D For Intemal Use OW.
1.Wen Contractor Information: `
Gary-Thompson
WellConnaetorName FROM •n- DESC8n7rON
4418 A o *z z '� r �•l�J Zs >�
YCWailCoatenetorCeetiBeetiar+Aram1� 15:O1FfRR-CASING u3aiN�easedweR4ORLINSR Ileable:
Aqua Drill, Inc. . 'FROM -M 1 DrAMM= I MUMM59%
Company Name• n "' -,r-;t- ` b.i.S is GA%',,, N` 7
2.Well Consti cdon Permit#:
�� -7 Lx<I rV �a �DVNSRCASWGOR-Ti clo
List all applicable ue0earrtruction pemtfa(de WC CamW,Mum vorlanee.atc� M M in.
3.Well Use(check well use): M & in'
Water Supply Wdl: FROM TO DMIEM SLOTM
AecWtuwl E3M cipaUPublic ft: ft. to.
Geothermal(Heating/Cooling Supply) �phial Water Supply(single) R R ia.
lndustrial/Commcicial OResidenual Water Supply(shared)
1&GROUT,. ..::r.... .: .. ..
FAquifer
on FROM b TEMAL F1113? alTHOD&AMOUNTter Supply Well:. 20 & ' � ✓ "ring :_ Recovery fao WelrRetdrsrge �GroundwaterRemediation19.SAND/GRAMPACB a ica"r Storage and Recovery Salinity Barrier torTest OStormwaterDtainage tZR
inertml Technology OSuitsidenceControl R Rrmal(Closed Loop) Tracer 20.DRnJMG LOGrmal(IiustinpJCooli Return) Other(explain under#21 Retntul:s FROM TO DssaemrtoK sin,eu
7) ft. /b f' tr C 'V
4.Date Well(s)Completed: Well M# p R Lj$ tL ;� 5a vC rot
Sa..Well Location: `1�- -L ft.
lam''H&%Ar �tem P-S 4, `01 g 61 k
FWlitylOwner Nam 'Facility WN(ifoppliwblo) ft
iil(o� ,rir Pt� 6►4 CG#-Ak, (L f6
lent Addrea.City.and i�Vft ►�. b
'2L RErdARKS
County Penal Idemifieadon No,(P1N)
5b.Latitude and longitudeindegreadminutesisecondsor decimal degrees. Information ProC .!
(ifweU field.an tatilongIssufficient) 2LCerdticatton: DVVR Section
Y, (y1 -7 N 7 5 e �Z'o 1,ti�t(,,� W o _er.2 j6
6.Is(are)the well(s)Qermanent or Temporary S(&. e Operfifitil WCH Contractor Dace
By x1g+dnS tits fam,I her*an&dta the rrrJl(s)mar(env)cannoned in accordance
7.Is this a repair to an eldsting well: O Yes Or m4o with 1SA NCAC 02C.0100 or 15ANCAC 02C.0200 MICanaacdon Mamfin s and that a
/fthis ito tepai.fill ou thunm rdi lar Mfomta m andatplaft thenatum ofdee QDP3'Of reaendharbeea pnwkfad rotha srell turner
rip*w dcr l21 rmwrb.imiA n aron rho haL*afddsfomL 23.Site diagram or additional well details:
L For GeoprobdDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I.GW I is needed. Indicate TOYAL NUMBER of wells construction details You may also attach additional pages ifnecesser) -
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: a (fL) 24a. For All WeILs: Submit this form within 30 days of completion of well
For multiple nrllt lint all Awdis iMWenaut(aamph-3Qa 20 and 2Qa 10D1 construction to the following:
I&Static water level below top of casing: (fL) Division of Water Resources,information Processing Unit,
bruw erievel it aboreCasio&we^T" 1617 Matt Service Center,Raleigh,NC 276991617
IL 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 form within 30 days of completion of well
17.Well construction method: f o+*,,c 4 p+•Y construction to the following:
O-r-auk-tmy.cdk d'aeetpush,em) r
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� Method of test: <bl. "' '24c.For Water Snouly&infection Weltso In addition to sending the form to
the addresses) above, also submit one copy of this fbrm within 30 days of
.13b.Disinfection type: 1��.`ta%» Amount; 1 6%,- completion of well construction to the county health department of the county
-,vhere constructed.
Fotm GW-1 North Carolina Department of Emr ntum Ud Quality-Dkisfae of%Vsw RcM= Revered 2-22 2a16