HomeMy WebLinkAboutGW1-2021-01630_Well Construction - GW1_20210430 :Punt-Ford`.
9JE1tL CONSTRUCTION RECORD( 11 For latemalUse Only:
L Well Contractor Iafbrmatlon:
Gary.Thompson wA•EZONW
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NC Wag CouhaoraeCmdaeatienK*mbw 15:OUTSRCAS>rIG fbi4alMtf:eaaedivelR RLIltBR
Aqua DdII, Inc. . FRast nnu •.. . —WE
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16 IRMNERCASRtTGOR URIM
2.Well Construction Permit#: �( 1`t S 1 owr m auatttme :aiAaz�►
Unt aft oppllaabhr woof counr=donpanim"WC.CooW Stare.Vaftm etej ffi ft la.
3.Well Use(check well use): R ft
Wait Supply WeIG M CttSBN::. .. ...;• ,:.. •.:'. ;.. -. : .
FR
Agdcultuml uaioipaUPublie. Oaf ft.
TOR D1A1<thT la .sl ars»?�
Gwtheneol(Htatiag/cooling Supply) OResidential Water Supply(single) ft. fL to.
lndustriel/Commetci it Ditaidential Water Supply(shared) IL GROUT,-
"Ilrditation FROM iitw AAAtonNr
Non-Water Supply Well:. D R 7-L ft c isien : Fi hod,
- Monttorin Recovery fL ft:
7a ectron.
R ft.
uiferiteehatge �GrotmdwaterRemediadon
u Stomp �Seliarty Bamer RO AND/QtAVEL PAC[C
q 'ifer rage and Recovcry F
M TO
Aquifer Test E)StotmwatetDminega R R
Experimental Te hnology 13Subsidence Control ft ft
Geothermal(Closed Loop) 07racer 2LDRMINGLOC:aprichadditisoalebeet3if
lGeothermal(HeathrglCooling Reutm) .()tier( lain tmder#21 Rmnartu) Most TO Ds s ex
O fk6 a ft.
4.Date Wells)Completed: -G-2•/ Well M#
Sa..Well Luestiom
�r.f,&,✓ a, qO ft ft
Fitalily/0wnerNome j_uA,.s�►el® $t,b;FadlftylDD(tfapplieablo) R e R Ciran.� c.
C.,rz55 ,,.,`►XQ Or �ic b,,,•, rv� ?153 ft R
PIWIWAddvarc MV6=dZip )) ft. R v
p�Win�lYvC �Zn'c? 2LRIMARKS )
Ceuaty Pmaol ideadficadonNo.(?IN)
Sh.Latitude and longitude in degreeslmiautedlseconds or decimal degrees:
rfwa118eld.one Wang fasutlident) 22.OecdfEcation: �•n����1��
7f F7 /K. 7��' W 1;��:,cr;, �'t' 0�
16-h(am)the wedl(s)g"aent or OTemporary sipom ofCirtiffe4well Contmetor Date
By sfgatng tits fam I hereby earl thm the woJI(s)ww Oretef eonwamd/n a=rdwee
7.Is this a repair to an etdafing well: 13Yes or [3NO irith]SA NCAC DIC.0100 or J3A NCAC DIC.DM Welf ConSvwdon mitdonkm d dull,
Ijfhtstsateperlr.JHlouttaosrntcallemattictlontnjormaHonandesplab+via traaaeoffhe ropyafthtrtemrdhasbeenprmidadtodreirdlowner.
trpa/rwxkrD2J namrdxsordan open dwkm EofthlefomL
23.site diagram or additional well details:
it-For Geoprobc/DPT or C lose d4xop Geothermal Was having the some You may use the back of this page to provide additional well site details or well
construction,only 1—OW-1 is needed. Indicac TOTAL NUMBER ofweits construction details You may also attach additional pages ifnecemy. .
dntled SUBMITTAL INSTRUCTIONS
9.Total well depth below loud suftee; 3 (ft) Un.For All Wells: Submit this foot within 30 days of completion of well
FarnmhfplemsdulyaIIdepthst/'dff-mreroetpfe-3@2DD•and2(o)IDD5 construction to tbeflonamns
10.Static water level below top of casing: 2A (ft) Division of Water Resanrces,'info matioa Processing Unit
8'water leW ts above cadn&are•=" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter:
(�•) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /-v6-.,.r!j A: above,also submit one copy of this fona within 30 days of completion of well
tonsauction to the following:
c, (ae.ate;Win.cable.di wpm%ere.)
Division of Water Resources,Underground Injection Control Program,
'FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 2769P.1636
•13a.Yleld(gpm) Method of test: ��`� k�j�' r 24c.For Water Sunnly&Infection Wells: In addition to.scrubg the form to
�? the address(es)abort also submit one'copy of this form within 30 days of
.13b.Dhilot'ectlon type: I 1 a Amount» /'y completion of well construction to the county health department of the county
where constructed.
Form aw-t Nmtitcadi aDepaaramtofswimnmeowQualuy-DivisionoftVaterResauas Rerind2M,2016