GW1-2021-01621_Well Construction - GW1_20210215

WELL,CONSTRUCTION RECORD(GW1) For bamal Use Only;
i.Well Confesctor Information:
GaryThompson IL io
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NC WaltCommemrCMdfi ad=K*nlff S:OI1TIDtCASIIVG ftmotti:emedweIIo RLWSR ' "Ilmble
Aqua Drill, Inc. . ar,�sttvteR MMML
Company Name• (� ft Li a IIL G,-is- lu. S DF-I x P L r-
iB 11MGISRVGOR-TURING'
Z.Well Construction Permit#:L,y S^'��'O l o4 Oa 2 o Z.t7 PROM I ID I DIUMM Iern r,
Lin aflapplf-bla mdl ooastraadmrpenWV(te WC C=*%Stem.varm m aW R rL tn.
3.Well Use(check well use): % i"•
Water supply Well: 17' CRBEN::. .. ..;• ,.<.r•. :.":..: ::::.,... >.
FROM 170 1 Dzeri 8R I sLOTtim
AgiicWtutal DM cipallPablic. {� !c te.
Geothennol(Heatiag/Cooling Supply) aural Water Supply(Mlle) ft. R le.
1ndusttiaWommerciel DRetdential Water Supply(shared) 1S.
Inc lion sauna VIA72RFAL t • .AIMMIaD&AMotarr
Non-Water Supply Weil:. Zj -a fL --14, , . " S
Monitoring Reco R ft. "
Yo)echoa. tL R
JAquft
g6iferRecherge DGrouadu�aterRemediatioa '
quifer Storage and Recovery DSaliaity Barrier FRO To PACs
Test OStmalwaterDmine egwrimental Technology 13SubsidenceControl R �eothermal(Closed Lou ) .p DTiacer 20:DRII.LiNG LOG atoaeh addhtoueishenatfeothermal(HestinglCooting Return) ".Other( lain under#21 Remarks) sRoar 'ro ass
a ft. 0 IFL PC� CI,F�,
4.Date Well(s)Completed: �- '�-t Well M# n ft. 35, R
So.Neil Location. S qb R, bra h• r
Le e R SrS %
Fa ilitylOwnerNaam %cithy Me(ifapplicahla) D• M
ft ft.
PlipfedAddvu%City.aadZiip & R
��1//•RkSry 21.
PJULAM
c�4y Pmcal Tdeatificedon No.M M
SL Latitude and longitude in siegrees/minutedseconds or decimal degrees:
(ifivell field,oneWant;O snffidea) Ty,Cerdlicutton:
r
W
6.h(am)the wens ermaneut or DT'mpomry Signs eFC ' ea Well Ca amrr Dace
By stgrdng dts fans.!hurby MO d-the Irdl(s)I=Omv)com*xwed in aoaordana
7.Is this a repair to on etdsting well; Dyes or ONo Idth ISA NCAC01C.0100 or 15AMCO2C.0200 Wdff CottstraedonSxdffrds and rhat a
lflhte tsa mpofr,jV owh mm irdl ammuctlanmformmlo w d esplam'theaaroro ofrhe copyofdth urea dhas been pmvidedto dm tedl corner.
rapa&wder(721 remw rswdmtopendxhaekof&sform.
n.Site diagram or additional well details:
L For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or wait
construction,only I.OW 1 is needed. IndIcsc TOTAL NUMBER oft =—SMUjMONS
You may also otmch additional pages ifne�. .
dolled: t ,:•y. �
9,Total well depth below land smface; ft Submit this fmn within 30 days of completion of watt
!•'ornmlrrpta,rgtlstlstatideplhsifcl�uon(araalpfa-9®20D'andt(�100� "�� ��nfollowing:
It Static water level below top of cadog: � ;=v;: i�r })1 ci'if Water Resources,'Information Processing Unit.
Ifamterlavl&aboveeasm ase"=" ` +� c, 1617MailServiceCenter,Raleigh,NC276994617
1L Borehole diameter. (in.) 24t�For Iniectioq Wells: in addition to sending the form to the address in 24a
Lt Well construction method: rd}b�y /� above,also submit one copy of this form%viddn 30 days of completion of well
G•e•-W.rot my.eaw4 am pox em)
construction to the following:
Division of Water Resources,Underground Irdection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �� IDYethod of test: GakcG.�� m 24L For Water Snnniv&Inhection tNel to'addition to.sendiag the form to
the address(es)above;'also submit one copy of this form within 30 days of
.13b.Dis afttioa type:„ �� -D 5V,5 Amount: /6 r/2- completion of A%IH construction to the(county health departrnent of the county
where constructed.
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FromGW-1 NorthCaroVuDepa==tofftdmamenWtlualuy-Diviftkof multesom m Revised2422a16