GW1--04122_Well Construction - GW1_20230623

WELL elNSTRUC °ION ® Q Tl �•'
1:f1fl8'1r01)11••
TEEMED_._ - � f For Internal Use Only.
•
1.Well Contractor Information: .Jf
•Gary.Thomp o 14.WATiEYt ,ON
Well Connector Wan) -
441A • PROMOPROMTO: • DESCRIPTION :•
•`(1`6 ft )•e o fre r..:•(i;, . (,e� C,(,, --
KC Well ContmetarCertt&eottaaWIber
Aqua Drill, Inc, .• 1 gt17CER: vG( �n1t d.e�ellalmlrguueRr�£ •ue ):'- :..:
TO _ THICKNESS% nversttrfas.
ComptumyName• 0 a 1-f'i) ft. (%ZS ft. 5bpa1 -0b�
( '1 16.fit+IitlER CLUNG OR•11JRING(geothermal dosed idAp):: - -2.Well Constuction Pemmint: L 101DM TO Dann � E
THICKNESS 1U 114O 'Lista!!appllcnbend!construction pe,nlIs(i.n.WC Conn%Stare,Variance.etc) fe, ft in.
3.Well tise.(cheelt:Well used 0. fe. • la
•
Water Supply Welk -
Agiicultatal • MOM TO DThu0Ef6R T •`'. .
'...wcipel/Publtc fe. ft, SIZE THiC19VESS Tfyp pr i,
Geothermal(Eieat ngICooling Supply) i•..i denial Water Supply(single) -
lndustriaUCommercial • ft
DRtsidential Water Supply(shared) „II GRom,..
Irrigation m7tOlit To nsamauu,' n'�en:+ ammo amsoultrr
Non-Water Supply Well:
f`'Monitoring Recov .--,Lb (5,4sb..k•e IPot.r t 4yd,
fG
Injection,Well: 14,...1(as
Manlier Recharge EjGroundaaterRomcdialion - •
ft
Aquifer Storage and Recovery �IStdlnlL}/Barrier '•1n•SAIVDlGRAYEL PACK(rfnmitimblo) .• . ... - .
FROM To MATER/M. EntpLocmitm_iernairicm •
Aquifer Test DStormwaterDrainage ft. R. -
Experimental Technolo '
E3SubsidenceControl ft ft.
•-Geothermal(Closed Loop) OTracer •20.DEEMING LOG.rattdehadditionalsheetsifneemeary)- •
Geothermal(Heating/Cooling Ream)mm) . Other(=ptain under#21 Remarks) FROM TO DESCRIPTION ogler•.w•a-.sanhartt •- •
0 fe. , 11s ft. eta
11‘L
4.Date Well(s)Completed:6-1 Well l tlb fe, ft.
dn.Well Location: .3.S ft:
C a•tr?t...• r.-
FacilityiOwaerMono •m?aeftitY10) ifappticabte) ft. tit
..� + • 1 .'....J-.r�"; eEsc, --.o
' t '-1� (i p 1 �e' t ft. ft ---
PNystmlgddtetr, tty.and2a �� �411 CJIq�l��t�VVL '®+•••�.1 4—ii �o .r
• S+LL P 3Z 6.e th it.
6l`3. 21.REMARffS .. • ... :6+ �• ?2,�i
County •
Pool Identification No:(NM
• 1t1¢.�arn;•-•n r,"•4•• .r,n;a'., IL('r•
t
5b.Latitude and longitude in•degrees/mimmteslseconds or decimal degrees: L'pry' `lt;
(ifweU field.once Wong is sufficient) , U.Cerflhieat(On:
1,C., ,_,Li t 30t'Sc.N ' ' rat 1 .A Lc !'
6.Is(are)the WeIl(s) ertrtanent or ' rr mpomcry •Si t ofCeaiftedWeil Contactor Data
�� By signing this fort,Ihete&cent(hot the vell(e)iras(mere]eonstrucredlnaccordance
7 is Ms a repair to an=toting well: Dyes or i re® with I5A NCAC 02C.0100 orISAIIiC7t:02C.0200 Well Construction Slumlords and that a
!fir is atepal.,fillmm known well tutuaucttoainformatlon owl aplaln'the mom elite "FT eirihr eordhasbeanPoddedED&wallowoor.
repatriate/or 0_1 tent&section oron di a hachajthfsform.
73.Site di gram oradditional well details:
8.For(oeoprobt/i)PT or Closed-Loop Qtieolht renal Wells having the same You may use the back of this page to provide additional well site details or well
construction.only 1.GW-1 is needed.Indicate TOTAL NUMBER ofwells• construction details.Yon may also attach additional pages ifneeessaty:.
drilled:
SU)i,ViUl'AL r'laT1tu1CnTONS •
r.
9.Total well depth below surface: ??_
h
Fort following:
udlipleweilsltslalldapths fdjjetcro(amnpie-3(a,E00'and2@,1009 (ft) fin';For Al!Alt e Submit this faun within 30 days of completion of well to the following:
10 Static water level below top of caslog: '2s' (ft.) Division of Water Resources,Information Processing Unit,
Ifuaterinr!lsahaveeasing use"-" 1617 Mail Service Center,Raleigh,NC276991617
11.Borehole diameter (in.) 296.For iniecaon Walls: In addition to sending the form to the address in 24a
• 12.Well construction method: (�S p•--of �',i above,also submit one copy of(iris fotmn within 30 days of completion of veil
(i.e.auger:now.eehte,direct push.eta) •
6 ,--
construction to the following
-F®1t WATER SUPPLY WELLS ONLY: Division of Wafer Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
• 13n.Yield(gpm) Method of hest; G as if—1� , `�+ - lye,For Water Sunk/ Injection Wells: In addition to sending the form to
• ����, , . the address(es)above,also submit one copy of this farm within 30 days of
136.Disaafectioa type: a AmonnG (� /2r completion of well construction to the county health department of the county
where constructed.
FormGW-1 North Carolina Deganctuan of Environmental Quality-Division ofWater RCSOIIICOS 1 ' Revitod2Z2201G