GW1-2021-04303_Well Construction - GW1_20210430

`:Print Form_ _
MILL C®NMUCTI®N IiEC01RD LW--1) For Internal Use Only:
I.Well Contractor Information;
Gaey.Thompson 14. ztnvas
Nil CootractorNama Flmnt To: D>iSCREFIIQIY
4418--A k'-xs fL z t—
NC Wall ContrantorCeetiEwtionMahar ft
15.011TER•% G .aiNtl :t M ORLiPIBR'
Aqua Drill, Inc.' mtonr TD DDdNEFER 1
Company Name• D 2 ft 6�].S; m• t U L
Ifa IIVNBR GAS7IVG OR TOBING dosatdco
2.Well ConsRaction Permit#: �. b(-thh FRom 'ro Drab» [t bwr�rni
List al!applicable hell cWwrueaonpermits(Le.UiC1 Coanry,StrohVartmtce,etca ft 1L in.
3.Well Use(check well use): R % in
Water Supply Well: t7.fiCR8t3N.
Agricultural FROM TO DIASI6TlBt t;i.OFl,1" Tffit blATEBTAL
crpallPabiic & h.Geothermai(Eleating/Cooling Supply) Residential Water Supply(single)
IndusttiaUCammetuiel 2 1R ta.
f3Re idential Water Supply(shared) IL GROUT
Trri anon FROM To
Non-Water Supply Welt: atATFRiAL Ht HAMME3 Tb1MMD&Abtomvr•
� � 1
Monitoring Recovery ft: ft. doS l -0t
Injection Well:
gbifer Recharge l C30roundwaW Remediation fc
AquiferStorageandR., 4 19 SANINGRAVELPACI{ a 'cable
?�Y �Salirtity Baaier FROM To atnmunr,
AquiferTest
0StormwatetDrainage ft R
Experfinentai Technology' [3Subsidence Condrol R R
77
Geothermal Tracer 20.DRILLI{VGLOG attichadditionatsireeisifneetasary
_Geothermal(HeatinglCoolingRetttm) nOther( lain under#21RemtuLs) FROM To DESQtiPIIpPr eetarLardn�.svahoek daweret
S a R' to Gldo
4.Date Wells)Completed: `l y Wall� a & 3 J5- M
--
!fn.Well Location: 3 fc 4f- ft. rbti A s t
Foeility/OntnerNomc Fa�ilityIDSGfappIieobIc) % M
fn 17�su 4
Physical Address,City,and Tip & R
t'V
ZL REMARI6
County Pmeel Identification No.(pm,)
5b.Latitude and Iongitude in degreedminutes/seconds or decimal degrees:
(if%vell field,one Wilting is sufficient) -
22.Certification:
3_ i�7��Z,S'lL4"Ny� -2 ,\
6.ware)the 111100Parmanent or OTemporary Sfgndtde of"ed Well Cantmetor Date
oftrg By sig dds jinn,!hereby art&►hot the 1my(s)tram(nerel cnnsdaaed in aceotdarce
Ms this a repair to an existing tt eil: Q �--��Yes or Eafk u trlth ISA AtCAC 02C.0100 or 15A MIC 02C.0200 iPell Construcrton Stan ar&and that a
jth&isa apart,figorrthnmrn ircllcmupuahrn Monmulon and cw1ain dwnanae ojdm copy offids recordharbeenprmQcdro fire uril mmcr.
repairander 921 rrmarksseedon or on the harkajtldsjorm
23.Site diagram or additional well details.
S.For Geoprobe/DFT or Closed-Loop Geothermal Wells having the same You may use the back of th s page to'provide additional well site details or well
construction,only i.GW-1 is needed. Indicate TOTAL NUMBER ofwells coms3ruaron details. You may also attach additional pages ifnecessary. .
drilled:
��� SUBMITTAL IPISTRUCTIONS
9.Total well depth below land surface: lam) 24a,For All
Farn Wells: Submit this farm within 30 days of completion of well
mhiple srelk lla all depthsd iir(fferart(example-3Qa 200'and 2QI00� S
construction to the folla ib
10.Static water revel below tap of casing: 3 b (ft) Division of Water•Resonmes,.Information Processing
Ijrmrerlmrllsaboreaas(rrs use"=" gUIItt,
1617 Mull Service Center,Raleigh;NC 2769M617
IL Borehole diameter (m.) 24b.For Infection We11s: In addition to sanding the form to the address in 24a
11 Well construction method; t- above;also submit one ropy of this form within 30 days of completion of well
(ire.auger,mtaty,cable.direct push,etc) construction to the follmving
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
I636 Mail Service Center,Raleigh,NC 27699106
13a.Yield(gpm) Method of test 24c.For Water Supply&Infection iWells: In addition to sending the form to
�
Vlh-j P"7O the address(es) above; also submit one copy of this farm within 30 days of
13b.Disinfection type: ____. Amount: 0Z- comnletitm of sail! rtm vtlnnrinn rn ti,............r.-..t.r _r m- .--._.