GW1-2021-01434_Well Construction - GW1_20210127

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Gary Thompson I'L WATERZONES
FWJH TO DFS�rrN
Nell CoatmmorName
4418-A 0 ft, r!1 m :r.l,. LSD )✓+
& ft
;1C Welt Conm+starCeaiRaatianN®bun - 15.OUTER CASING for maid-erred wens OR LINER ifa Gep61e.
Aqua Drill, Inc. FROM TO DrAslEtEB TICNI s nu
o m I y �- rt I e'.zs In '/
Company Nama-
16.INNER CASING OR TUBBVG thermos dozed-laoal
2.Well Construction Permit#: Ir 7 d �7 GL-t' rV '� FROM TO DIAxeiat TMCKKM MATERIAL
Lut all appfka6le uelf wwmcmon pertain(Le UfC Camry,Sao,Parfame,ate) it, R iv.
3.Well Use(check well use): a n,
Nnkr Supply Well; 17.SCIUM
Pp FROM I TO I DIAMMM I SURSIM ICr4iE4 hN
Agncullu al OM icipsUPublic It. m in.
Geothermal(Heating/Cooling Suppiy) - mid,atond Water Supply(single) 2 I R la
IndustriaVCommemial OResidenual Water Supply(shared) I&GROUT -
knatition FROM NUITRIAL I FlifliqACEPAMNIFIRWAA1001fint' -
Non-Water Supply Well: C3
8 ',),b fe ",-I,r(7n, c / ,' = �� ✓(i
Monitoring Recovery fa R.
:ejection Well
2 ft.
Aquifer Recharge ©Groundwater Remediation
19.SAND/GRAVEL PACK a i
Aquifer Storage and Recovery OSalinity Barrier oil TO NUTMUAL EbtPIACEs E &n7rlmn
Aquifer Test OStotmwater Drainage ft 2
Experimental Technology OSubsidence Control fl n,
Gemhenmal(Closed Loop) OTmcer 20.DRILLING LOGmanch additond sheets ifoaessorc
Geothermal(liesting/Cooling Return) rjOtber( lain under P21 Rernefh) Fnost TO D64liPflDN alm.hada rmvaaa emir Yv.ea
p fa 01
4.Date Wallis)Completed: �-(,_,'l Well IDO /D R �/ Q' -' 5. s, ram-
So.Well Locatium 7:r 11, -L R' gltit w Y
l.v`N&De-- �ameS -el IL �31ti Gam, y
Faeiliry/➢wner Nnom (n1 n Facility mg(iropliabb) Itmil( � Rt-p Rt'ErG PX Grnkw er Nx/m-A.y Zl5 ft. R
p6rdrn1 Address,Car.and Zip �uvis^+�'d..�ri Stib, & R
21.REMARKS
Alter .s.�:e 1 + -2-t4 JAN
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees- InfC" -
(ifwea field,one bViong is sufficient) 22 Cerdlicadoa:
� -t z, ('14Y N 7i ` i ° 1 y��., W
6.)s(om)the wefl(s) ermaneat or OTemporary Signarlaft ofrmfid wen Cmeaetor Data
By mgning dds Jima,1 hereby eerljy f/rar da:+rdl(s) mr(ova)mwr ed Jn accordnrce
7.Is this a repair to an existing well: []Yes or QNo rith I5A NCAC 02C-0100 or 15A NCAC 02C.0200 spell Car nucdon SYa Janis and rhut a
Ifdiir uerepAaftllea,knotmwellammal/om trforoaman aad e&ae dam ore ofthe caf'3'afthu remadh.beenpm,-lded run thendl artier.
mpair order 921 rcaarkr seciian or as the backofthisform.
23.Site diagram or additional well derails:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional Weil site details or well
construction,only 1.GW-1 is needed. indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessery.
drilled: SUBYDTTAL INSTRUCTIONS
9.Total well depth below lad surface. D - (fi) 24% For All Wells: Submit this form within 30 days of completion of well
For muftiple,,JG list 411dgedafdifferemr(crimple-3 06200'mad2@1001 construction to the failowing:
10.Static water level below top of casiug: <5 (ft) Division of Water Resources,Information Processing Unit,
lfunrer fnYi uabore casing me"-" 1617 Mail Service Center,Raleigh,NC 27 69 9-1 61 7
11.Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
I2.Well construction method: r,D r,c 1 IN:e, construction to the following
(La-auger,many,cable.daeet Ptah.etc)
Dis{siaa of Hater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �-� Method of tesh «�1,-a ^ t 24c.For Water Supply&Iniectioa Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type W-�-IDX Amount- 6%:- completion of well construction to the county health department of the county
where constructed-
Fame GW-1 North Carolina➢epamnat of Environmental Quality-Division afUrater Resamces Raised 2-22 2016