GW1-2021-00808_Well Construction - GW1_20210215

`` Pfirit Form
WELL CONSTRIIC UON RECORD(GW-1) For bftl l Use Only
I.Well Cmhutor fobem d m
Gary Thompson s
Wall CamcmrNsm %. ..
4418-A vsR [.. R ��,- SCE
NCw4ICerdmwCwdfwaewNr.►r 75.E R 'LS )R
1i M. -
Aqua Drill, Inc. . air R o R (, iS b 5
CompsrpNm
2.Well Caushuctloa Permitik d nC)(12
fwdamwei 1eea0m,mradmperwm Ra lOC Co SpR Ymrmer.rU R R Is
3.Well Use(dm&wef aver R R Is.
T
abrrgoPluy Wdl: ..
® a R o.
(sudermdW(HealpCoohgSup*) �R wdwswly(sb*) R R Ie.
Induvtrmvcommmami QRebllmud Wow Supply(Awed) ILGY00"1101811tion in
- -
•
Non-Water SuppyWelL• J R 2S R nn--�d-,ti l-
lJ e_ tir d
Ma R R
® R R
SWW ad Ramiery Qlalmd)'BM7er IL YB.
TO
Test QStotmwmr Draiosgs R R
matted Tadmology, 13Subsidmnee Coniml R R
Geothermal(Closed Loop) QTMW 2!DRILIAM WG bank sidelined shism,er
ad Reamn0lber(seplam uodwfi2l Remarks
c" R
4.Date Wells)Completed: I -a-`i- )_k wellMO ( - R p R r- S+-.A,
Ss ell Loeatlom CJ�:�> T; R q fL I s
Fmilft)YDwdrNdar -14a7fa McCrfWpSabla) Iv R -1--5IL
fie 2—?01 - R R
Pfw"Adda Cmy.mdZip R R
a �
FRtcd Idad6adoo Na('IN)
561rtimdeand bagNada in drgram/mlartmiseemds w deefad dqr
(tfwe0&K m bblaef is aomeimt) 22.CwdRtatbm
6.is(an)thm we0(v rmnent w DTemvaMq S,grtaa of Wrll aaeaapr Darr
L Hb t b ma �/'rivd^a dd*Jbce'f aa�i' 'el'da we""m(r q owueed 6,eawdma
7. twpa4 attbSag asih ©Yet w Io r 2Q VM 1I4 NGtC aIC.0I00 or IJA AC1CO3CMile wecaemme ,Seaimtad amd
#'dtradrgrR,JlfwrI de0 I etbr.mn,ndsw"airG4, ^Py dlwr,r Wk.6de,p.dd W,d.wi*o~..
nparr,wdrral/mwairaedm orw dff&vkdfd4Jam.
29.Site dbgram or additional we0 dmella:
L FbrGeopobdDPrw Clomd-Loop Geatbermd Wd k.Ldktgdpnm . Yon may use ilia beck of this;pep to provide additional well she details or well
only LOW-1 lsnecded hat"b70TALNUMBERof4mUs. conmaadon dmdlt. You iney @W teaI addbionelp an Ifnaoemny.
Mld
9.TOW will depth below lead wr ew 24a. For All Wells Submit hie him within 30 daya of completion of tve0
FsrrdeyN,dlr fwalfdwdaF f I�t00'mrdl2tg/009 constitution to the following
It Static wales level below top ofcedag: (ft) Division of Water Reap wn%lofbrmatlon Proeemlq Uu%
(/rnwlwdbdtowadxg"d-'- 1617 MSS Service Center,Rablah,NC 2789-1617
IL Borehole dismetet: (to.) 24b.For Islecdoo Wells In addition to aeodk4 the farm b the addles in 24a
12 Well coaarveeon method: f above.also submit arm copy of this form within 30 days of completion of well
Cudo�mmy.abli,Awpa4my con uaionmtbeblbwing:
FOR WATER SUPPLY WELLS ONLY: DtWsfon of Water Resourea,Underground Injemlen Coand Peofrsm,
3636 Mall Service Canter,Raleigh,NC 2709-1436
I3L Ybid(gpm) Method of tft 091,1 I 24L Fw Watw Sandy 8,Injection We0e In addition to mtalbg the form to
134 Dhdathetlon typo off, A - a the addraKes) shove, alto submit ane copy of this brm within 30 drys of
r cu mt: i G /z— complmon of well construction to the county halth deartnem of tlb county
where Consmsted.
F=GW1 Nadi CwlmDspasum oMmmounnad Qum*-Dt wmi oftVdwamduem Rwin,12M..7016