GW1-2021-00287_Well Construction - GW1_20210127

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WELL CONSTRUCTION RECORD(GW-1) For Ittiemal Use Only;
1.Wen Contractor Information:
Gary.Thompson 14. ZONES —
WallCommorName FROM Tv: Dt ntnv
4418-A ft.
- -- -- ft.
MCwouConanotarCMM,,d—NUMLar 15.0UTli -MING fii:�tltase83vem ORLINSR
Aqua Dnll, Inc. . 'VROM TO SUMEM -.
Company Name• & '1Lj fL �.2� t� '� Ga( nj*
—/V�D t. ,►� I&INNERCASIIVGOR-TIiBIIVG dosed
2.Well Construction Permit* \ � �-D FROM TO I DIABOME t I TERM-ss MA1RBiAt.
List al/W11cablenw0constrwilonpannits(Ee-WCCanty.Stow/tomato&eta) M R In.
3.well Use(Check weil use):
Water Supply Well. TO DIAlEB 6 -. •.... I M .
Psoxt BIELOT81z£
AgdctdtwW MMunicipaUPubiic R ft. to.
Geothermal(Heating/Cooling Supply) 5%( iMca w Water Supply(ogle) fG
IndustriallCommercial 131tesidential water Supply(shared) ILGROUT.-
"JIrrilmdonFROM ro AMERsrni CMk9XrAMM0D&AM0tM
Non-Water Supply Well:. 2.3' ft: 4
Monitoring E31tecovery ft. &
Injection.Well:
Agbiferltecharge DGmundwaWRemediation
-19 SANDGAVELPAC; a
A uiferStomp and Recovery ry [3Salb*Barrier
FROM TO I MATMUAt. I MOUCOMMIMIam
Aquifer Test oStomnvater Drainage & &
Experimental Technology 13Subsidence Control R R
Geothermal(Closed Loop) 13Ttacer 20.DRUAMGLOG aitaehaddMooalstteaftif
Geothermal(HeatiWiZoolingRe=) Other( lainunder#21Retnaft) FRont To DSSctnrrtorrmtor saattodc stmM
it o c nil
4.Date Well(s)Completed:XZ=3a�o Well Mo v5 fL (.ems ft.
9n..Well R Location:
i (6 ft.
W ew � �'TDme fL $5- R
Faeility/0wnerNamo &CHity Me(ifapplimble) R' f
�.aS�l Gewl-�,t-:v►v (�1n\r �rn�w[+� c. '2-7�SSl R R. .T7
Phyu*d Addmss.Cdy.and2ip ucvr 5�''e�� to�j R tt
. j
,/� 21:RBMAR1t:5
County Parcel Idca fiaation No.MM
5b.Latitude and longitude in degreedminutes/seconds or decimal degrees:
(ftell field.one tarllong is sufficient) 2L Certification:
6.Is(are)the wellwe mauent or OTemparary Signamm oFChdfie4 WeWConft=r Date
� By dgoing dds farm.1 hereby c-0 that die i dl(s)—0—)omuda Galin aacerdana
7.Is this a repair to an existing well: Yes or Ox/o. trlth 13A NCAC 02C.0100 or 13ANCAC 02C.0200 WeffCottmvWan�'atidards and that a
1f Ak is a repots frUma ham ttwlleommw1on lnfomtatmn and a rpkb the nano of&v copyafthls rwmtdhas been prorldedm the trcl/o�mer
mpairwxkra21 rawrkrswmm oron the bm*gfthtsfam. 23.Site diagram or additional well details
8.For GeoprobeMPf or Closed-Loop Geothermal Wells having the same: You may use the back of this page to provide additional well site details or well
Co imction,only i.GW 1 is necded. Indicate TOTAL NUMBER of%velis construction details You may also attach additional pages ifnecessary -
dnlW- SUBM[TTAL INSTRUCTIONS
9.Total well depth below land surface; 1 (�) 24n.For All Wells: Submit this form within 30 days of completion of well
For amltiple ire0s/in ofArda/fcVeratt(ample-3Qa 200'and 2 1001 construction to the following:
I&Static water level below top of casing: `! (ft) Division of Water Resources,Information Processing Unit,
lfanterlevel is above casing:use"r 1617 Mall Service Center,Raleigh,NC 276991617
IL Borehole diameter: (in.) 24b.For Iniectlon 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
It Well construction method: 'Z' r p: construction to the following:
(u augeti rotary.caw duectptab.-)
Division of Water Resources,Underground Injecdou Control Program,
FOR WAFER SUPPLY WELLS ONLY: 1636 Mar'1 Service Center,Raleigh,NC 27699-1636
- -13a..Yield(gpm) Method of test: <-b"!4`"t- 24c.For Water Suauly&Infection Weltso In addition to-sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
.13b.Disinfeetion type: ]Lkk l_�4 Amount: (4%- completion of-.well conshwdon to the county health department of the county
where consuvcted.
Form GW 1 - North Carolina Depanmmt ofEnvimamemal Quality-Division of Water Reramm Revised 2 22 2016