GW1-2021-01774_Well Construction - GW1_20210430

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M1E�GQMjMIIC M RECORD L( -Ij For lmemaluse Only
L Well Contractor bibrmadon:
Gary.Thompson w „ ,
tYallCowraenorName rlS R t4
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.rcwenCamtoam�ce�laeeaanxomber & f
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Aqua Dnil, Inc. : FROM CASII DzunMM ; ••
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Company Neme• 0 M S"SS ft, G,2.S tn: P v t.
ItF IIEAiSRCIISDVGOR•TUBING ..
2.Well Construction Permit#: �I QX—UW�AM —OOG p FROM I TO DI4M6IBt
Lisa afl app(lcable mil eonowdonpemm(ta WC CMV.Sant VaYMM OW tL iG 1n.
3.Well Use(Check well use): % 1O-
WaterSupply Wct:
Agiicultmaal unicipal/Pnblie TOft. ILD1ADt6MM swrom Mc
am
Geothermal(Heding/Cooling SMl.Y) identiai Water Supply(single) fL. ft te.
IndustriaWammemial DRefdentcal Water Supply(shy) lg.GRtAiT..
Irrigation FROM To AMjMttL4La s ODxr
Non-Water Supply Well:. fL iZ
:- Monitoring ! Recovery 06 ft. • Otis w f�4c C
Iecdoa. 1: fL
AquiferReehatge 130mundwaterRemedfetion '
19 SANDIGMVEL PACK-Of sonfleablel
Aquifer Storage and Recovery DSalinity Sorrier FROM
ilw- on
Aquifer Test C)Stormwater Drainage R
Experimental Technology OSubsidenceControl IL fL
Geothermal(ClosedLoop) [3Tiocer 20.DRHJMGLOG atttiebaddhloaataheatsff
Geothermal QWnglCooling Return) 001her(explain under#21 Remod's) FROU To ft ors
4.Date Wells)Completed: "Z•l-1l Well MN fti c
Ss..'*Vell Lo__caandom `` b to Cs ep p-
fL
FdeiGty/OwnerNcna�me l Facm�itylDll(ifapptienblo) R R
e{?,2b `�I,'tr�l►h� G ir" bo-b wc- 2?4 ft ft. ?a i 1 E
ptyc(W Addmm,CiW.and Zip
ft a:
G,.91 E rdL Z1
CountY PmRal Idead6eedon No.(FM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: --c-3*sjrQ Unit
Ofweu field.one Mug 12 su ident) C�s -1:1%S toil
22.Certfccadon:
�Vloa, t5r► 7911/ N 79 SV Z9 . (-qI! m) W
6.Is(are}the wells) Permeaent or DTeanporshry sivet ue eF • C4Iven can-metor Dace
B signUtg dds fomx 1 hereby coo dmr die=JI(s)-wav(irony eonsovaW ar accordance
7.1s this a repair to an exbftg well: Dyes or 0*0 mrla 13A h!C.tC o1C.0100 or 13ANCAC 0?C.0200 W&flCansnw lon&x dff&and Ih n o
Iflktrtra mpab;JF!/our6roim mall oar crPon h{fomunlonand erp/afnYhenaam gJthe copyof is moo dhas been prwidedtodoweii owner.
repafrarrderA?I rmmrArroedonoranrhebadEoffbiaform
23.Site diagram or additional well detects:
L For GeoprobeMPT or Closed-Loop Geothermal Wells having the same You may use die back of this page to provide additional well site details or wail
construction,only LOW-1 is needed. Indicate TOTAL NUMBER ofwelis construction deuft You may also attach additional pages ifneeessary. .
dolled: SUBMTITAL VVISTRUMONS
9.Total wall depth below sand surface: (ft) 24n.For All Weller Submit this form within 30 days of completion of well
Foramldplewdkltrtalldepdwfd/ mVe-3@2M*-d2@100j construction to the following:
10.Static water level below top of casing: K (ft.) Division of Water Resources;Information Processing Unit,
)fatrterlarllsabovemsfng use~{' 1617 MR Service Center,Raleigh,NC 276994617
IL Borehole diameter: (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
,/ above,also submit one copy of ibis tbrin within 30 days of completion of well
11 Well construction method: M 6=r I e, construction to the following:
PA-W.-MY,«NR are"Insk em)
D"fon of Wnter Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Macs Service Cantor,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Z— Method of test: Gp�J` �h>�e 24a For Water Suwty A Infection Wells: In addition to.sending the form to
c o the addresses)abavet also submit one copy of this form within 30 days of
.13b.Disinthctfon type: 7 A Amoant: 6 % completion of well consruction to the county health department of the county
where constructed.
FGMGW-1 NonhCszvV=Depm==tofEmimumenW Quality-Div(sfonoftvawRosomeas Revised2,22.2016