GW1-2021-01625_Well Construction - GW1_20210430

WELL CONSMUCTON MOM C -1) Far b0mal Use My—.
L Well Contractor Inflarmntimi:
Gary.Thompson 4.w TEIt
tvoIIcoauacrorNaos 1�so>ss �'
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aC Wall ContamaoorCesetHeattor►Nimbar IS:OUTER CMIM fbi smd�eatedwdto RLINER IImble
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CompagyName• C7 it, `7 5 fL C,]-S IL
IB II�IINERCAStT1GOFL-If IING
2.Well Construction Permitter �d(o L'i e,i N �-L om TD
[M all applt-Ula ire cottsnwounpetmfn"WC CwM.5 xum Varrm m ety M R �
3.Well Use(check wall use): R ft
WeUarSupply Wdt: 17'SCRM
PROM TO DIABrEtBR SLOT
Agdcultund ttnirapallPublic. ft gt, lo.
p(TIM":
othermal(Hesting/Cooling Supply) ' emiai Water Supply(*We) ft ft ta.
htiai/Commetchd Dlteddential Water Supply(shy) 1S.GROUT.. ,
don FROM MA AMnWD& otnvr
Non-Water Supply Weil:, g� ft 7-� ft
:- Monitoring Recovery ft ft
ec oo. e :
AgbiferRecfmtge 13GroundweterRemediadon ' tZ
fbt StorageandRea:o A&SANDRR2AVELPACK a
qui very nSalinity Barrier FROM
Aquifer Test E)StmorwaterDnunage Q
Experimental Technology 13Subsidence Control ft fa
Geothermal(Closed Loop) :21)DRII.LINGLOG audchaddldundsbeosif
Geothermal(Htating/Cooling Rearm) thlter( lain ttnder#21 Remarks) FROM To asscamrrox for
d tt a cl v
4.Date Well(s)Completed: ��-l Well M# R -ya 5 a;
5n..4Ve11Locatiom ft -D D' �- "ot7. J>, •
61 �,,i �br,,e.S `ter ft. 7r fL Grnry'
FaviliitylOwnerNamo Facility IDS(ifoppliwble) -7 S-ft i AI$ ft
I/Xo S1ry �J�l�e Lt` —u�ti.s�+61c95�.�b Grgl.aarn►� ft ft c
:Add &ensc, yaadTip '-'� �0` R g y
l-s- 21:RSMARtO; , 711
County Patcal Identification No.(PIN)
SL Latitude and longitude iadegradminufalsecends or dedmal degrees:
(ifvte0 field.am laulang is sutKdeat) 22.Cerdiicatloa:
6.Is(am)the well(s)(3faermanent or 13Temponwy Siena of i6ed tvel Con&.. Date
B9 stgNng drts font;!het+eby arr(fy dror r/rc;xsN(s1 oar hrurl eonspaaed m aaawrdamx
7.Is this a repair to an abling well: E3Yes or Oleo mith!SA NCAC 02C.O100 or lSA NCAC 02C.0200 Weli!CbnmvcdonSw*ri scold Chart o
,r'*klsanwtr fdiowb mmlrellw»wrJgfomwiwandapkindonatrnrofdm copl'ofthkrm dhosbeenprovidediotlairdivirnen
mpvkw der:l21 teamrArieW n oroa the bachof&sfo m. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Welts having the some You may use the back of this page to provide additional well site details or well
constmction,only LOW-1 is needed. Indicate TOTAL NUMBER of yells construction details You may also attach additional pages ifneeessa): :
dulled: SUBME AL P STRUCTIONS
9.Total Hell depth below hmd surface: lfw) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For nudriple=11,hwall&pda jfdobw farample-3®2O0'and2@1007 construction to the following:
I&Static water level below top of casing: ys (tt:) Dividen of Water Rewurces,!Informstioa Processing Un%
lfmoterlewl k above cadnb,use"=" 1617 Mail Service Center,Raleigh,NC 276994617
IL Borehole diameter. (in.) 24b.For Inlecttou Wells: In addition to sending the form to the address in 24a
Well construction method:- _tbf�- above,also submit one copy of this form within 30 days of completion of well
12
f- .may.ave.��.ate) 1'�` construction to the folio�ving I
Dtvisioa of Wafer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•13a.Yield(gpm) 3 Method of test: 24c.For Water Sunniv Injection a►eus: In addition to sending the form to
o/ e the addresses)above, also submit one copy of this flan within 30 days of
.13b.Dltiinti ation type: `�1�?a /'y Amount: 6 �Z completion of well construction to die 'wunty health department of the county
where constructed.
FmmGW-1 NorihCatolimDepmRmmtofEavimameotal Quality-DivisionoMMeritemu es RrAnd2,Tt.2016