GW1-2021-04655_Well Construction - GW1_20210514

WELL CONSTRi3CT'ION RECORD( 11 For Intemal Use Only
1.Well Contractor Information:
Gaiy.Thompson
1 WATftR
WaU t.canaetorName t?aost m•: •'
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MC Wen ConheamrQeettfieettonNneet� la'ty�tti�`rll c,�^?�i1 19:OUTSR_CAM ftfrmuttt vet ORLIIM Um6ie -
Aqua DdII, Inc. : pw ..�� 'ro Dwtssra ..
Owpary Name- 0 IL r � y•�5 � 5DF,�" ue
RR 16 tNNEMR- NGORIUBM ."
L Well Construction Parrokt;k: Y�5 P �•C�a 3 LI13 N m DIABIETM e1e77�u►e.
List atJapphaabla treU eanmvWon (Le[NC.Cbw*&State,Varfa rm W4 R f°^
IWell Use(check well use): R tZ
Water•Supp(yWeilc ISCRSEN::. .. ._;•. ;. .,; ::: ::. .;.• .:: ,
Agdcultutal �MnmicipaUPu6liC. FROM D7Ab1b7yaR 81.OTt1lZfi
ft.
Geothermal MextiOWCOOling Supply) �Residerttial Water Supply(single) ft.. R
industttiaUCommercisi Dltesidentiai Water•Supply(shared) 10.GR011T .
lrri tion oat To arA7Eaur.`. arrrnton� true
Non-Water Supply Well:, d fz fL �,. C�,'
" monitoring Reco g, ft
ectioo.
AgbiferRecharge DGmundwaterRemediation'' ft. ft
quitbr Storageand Recovery �Saliaity Harrier �OSANDIGRAVEL4ACB a 'enbts
TO
Aquifer Test OStormwaterDrainage f S
ExpeBmentalTechnology 13SubsidenceControl ft. ft:
Geothermal(Closed Loop) 13Traw :2LDRMLINGLOGadachnddtdaoalaheeaif
Geothermal Heating/Cord Return) Other( lam under#21 Rommim rrtoat TO
.. asstatmnox
t7 ft: ZaC a
4.Date Well(s),Completed: L(—a1 l Well M# D fZ 06 ie'Irt
Sa..Well Location: G
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Faoli(tyy/OwnerNomof "Facility iD8(ifopptkabla) a ft.
P4%fW Address,City.aadZiip ft tL
SL1t`r�,) Z1:RSMARKS '
County parcel ideadoewonNo.(PiK)
5b.Latitude and longitude indegreadminuteelseconds or decimal degrees:
(ffureU tieid,am lstilong is sum dent) ZL-certification:
d i ,��2» a " �,
N _�� �l� �?. 3�y W
6.Is(are)the wa(s ermauent or DTemponuty si a 04Iven Contractor Date
� BS'stgaing 1 forte,I hereby een(fy dmr de,rdJJ(s)tmr(here)compacted In aoeardaaa
7.Is this a repair to an existing well: Dyes Or 0� 0 trllh RSA NCAC OIC.0I00 err I5A NCACOZCAM IYd ICotrrtmedoaSftn& dr and that a
�'th4rlsarrpaJrjXJoxrlrotsnuYJdwnaiartlonbrfomtattoaamdapJcfa"drersatraegjdx �Pyaldittreaordharbemprm7dddtoduurlio�rne�
mpalrrorderd2l mmnbsawtaroroatheback�'ddaform.
73.Site diagram or additional well details:
L For Gcoprobd=or Closed-Loop Geothermal Wells having the some You may use cite back of this page to provide additional well site debuts or well
tronsttttction.only LOW-1 is necded. Indicate TOTAL NUMBER of►vells construction details. You may also attach additional pages ifne"Awy. .
dulled: SUBMITTAL INSTRUCTIONS
9.Total well depth below Iand surface: A) '24a. For All Wells: Submit this form within 30 days of completion of well
Fdrnmdi4 desalts dtttaiidepdw rd(&mw(avanvJe-3@260•andZ@1007
construction to the following:
It Static water level below top ofcastag: (fL) Division of Water Resources;Information Processing Unit,
Ifanter Jarl trabareoatatg ate^+" 1617 Mail Service Center,Raleigh,NC 276994617
1L Borehole diameter (in.) 24b.For Infection Weiss: In addition to sending the farm to the add eess in 24a
12.Well constracdon method: ['vr�6ee- 00 above.also submit one copy of this form within 30 days of completion of well
construction to the following:
Dtvlsfon ofWater Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
33a. t: G
Yleld(gpm) ►��- Method of test akki�-� M e- 24 For Watar Sunaly&Iniection Weill: In addition to wnftg the form to
D d the address(es)above, also submit one copy of this form within 30 days of
.13b.Disinthetion type: $ Amount: )6 t— completion of well construction to thelcotmty health department of the county
where constructed_
FarmGW 1 NonhCarolfimDeparneeatof6avimameatalQualay-DimoaofWaWRanta s Re*W2M.2016