GW1--02725_Well Construction - GW1_20240507

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WELL CONSTRUCTION RECORD GW 1 •
ForInternal Use only
1.Well Coati e.tor Infoimatl ono- • • ,,
Galt'•Thompson
• Iwdu ContmctorName .
.. . • :14.WATERZONES.-. �.•
. • • tprto
. •441&A.
65 'L f C 'c
- _ :NC Well Gantrectm'Gemtifieetioa Noni6er . : . ' . . � ! n .
' tf Oc_
8 :&Q
.Aqua Drill,Inc t • 15:OUTER GA3IIVG or todtiraaed wep,.OR 1LmhER
_FROM' To.. DIMMER,
Comp�ryName �' IbQ
. ' ,. .5- . . S R _Ps� _..
2 Well Coiistruc4lon Permit#:`�/,,F sxo
. LOt ell applicable xel rnnvbapinn perew&v Re.Ul Ccwiiy - MATEum .. '..- . . . . . . Slarq•Ymlohh�� tL'CASIDI
3•Wep Uae:(checktyep dse: .
DIMta:P@t
ter SupP>YY'Well. :•l7.SCREEN: -
::.......
. .. S Agricultural , RiFRosf To
•.••- .. ..
MtmicipaVi'ablitd i r . ,,,
Geothermal(Heatwg/Cooling Supply) Residential`Water S i .
Ind !iPPly(angle) .
� 4 ®vst�>Baw.
. .• • . ustnaUComriienrial : .• a�S + � R: • to. -
.� deithal W
Wells '•
Nn-Wtepply •:-. = •
.a• r Su • • 1. FROM i. TO .. 7T$UAL GBMPdYI'MEiHODikA6fOUNT
Mmiltoriiig_ -.
fk
. o •
In eanitO ep• •- ' id •— , I . Pnl�
. •.. . Ig Aquifer _ .. . .. • • . . .
Recharge
• Qt,- Dndwaterltenredtetion.. . .. .. '•�4 • :. �. '
. ' I�AquiferStorageandltecm, y . ' : :.r3garndyBairiet• ' .., 1 • : : • ;`19 BAND/GRAVELPACK f 6eabte ,.
Agtirfer Test • . . FROM ..! .TO tnA�nrnL
E�EkPuimentalTechnology : . Dmtwatg.Diarn• , • t�- �tnactuimtrrtaeigoD
O.` dence control ;: .R.I.
Geothermal(Closed Loop) • '-: ! • .
: b a� :041 . tdr 20:'D INGLOG
.�GCothCifaal :'!i; C�i i .L•f_' _• _ R�L attach.
altdit1Da71t�I�lt/it
•- iii filer : .lain under FROM '' .ro __
_. #21 Rem ' 21SCRIr11 eo4r
i q
:4:Date Wells)Completed:. - d`
Glin
Sa.,WCII Lo*U 11: , 5 .q
o' elan . ,
Cle:.l do,•11 nneS( �1 tk
FaoiGq►/Ouar Name ----•`. . . . •• �Ti'1
11t•t
P►1
• Facllity,ID#(ifappLonble) • 47 j • f`
aQ �.�1b4 b • . .
Paiee
REMARKS
. lldcngfitntion No.(PII� � � i
. •Sb Latitude ,•�'
wit loaglttde la d /iniintes/seeonds or deefmal` •
. . ••(ifwellfield,.onolad(crng>saufficieaQ .." - ' :..)..�+:i.. •
-
•
* :.... .' . .30:g61.SS"'t°.:.. :•.. -.- : te 1. -1-2- iA , : -- .--
-- -• - . ;•• -- - ••• - •• • •••!•'• • •• • :- . . :.•• •.: : -• --..:-.•• • .- .. . :... • •
•
•:... . . :
6.Is(are)the weli(s) Permuent .orC{T •
• . Dati .. .
•
7.Is tLis a• ••• •won e�dstinE Well: Yes o'. it
rip: F1'signiv ids form!hereby eertifr that the tadlc9)hvar(utneJ oomrmcti in caeordrmee': .
lftdsLs°hrpei Jt$o°tltwwawellc»+ell: -U '--..'''•• ' • with1.34NCACO2C;0100or.ISANCACO2C.0200Wega stnuctIon ,
bOtatatton and explatii the namre°file e114;if rcie»idleasbeen
. repalranQer#2!narimkv,Teetlot�erne tlebeekofthlsfosah. .. Stmrdards'mhd that p -
Prnvldsdrotheicellowuer .•. , • �
8.For. ro • . -- 23 Site dta ram or.additional weR details:: -• •, 1
p be/DPT or Cloicd-Loop Geothermal Wells having theleame' •Yo>i aaY.use the back:of this fo
' ronsttuchani only 1 GW 1 is needed. Indicate TQTAL NUMBER of wells. • oonatnicaon details.You tirap also
•• drilled. �• '. : � .. �; - ,•!
de additional well site of well
additidnnlpages if
1.
9:Total well depth tido:wlead surface: ass .J.:: . - • •• I-
; R N8
For'multiple xrllslrst°A' the • • UCTI(1
doh lfdJaent(aompte 3Q200•mhd2(a�OD) • co aF, All a fo Submit this firm within 30.days of comp•letion of well I
•
10:Sfntic water level below top.of caetog: ' :._ So ... . • 1 •
.• Ifsuterlevel is above rosin&use:'+•• '. .. (ft Division of Water Ren•o •
•
•11.Borehole diratiieterc, .: '. . . `1617 Map . .
aiceti,Information PnoceasinQ Uaif; •8ervlee Center,RaNetEh;NC276991617
•
(�•) ••
li : In
12.'Wep construction method: . above,.14.oostibmit'oao Copy oft is foi*witbm 30 days of oni Ieetio to.setiding the:form to the onn of
... I�o•�o►ry Air. .. .
' (i•4 `. Y,cable,.tiledpnsp,etc.) - con:07,ton to the following l i well. '
' P
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Undegeooiid injection Control Pro•. . tCr gam' ' .
13a.Yfeid
•. I•- 1636 Map Service Cen .Ralelg6,NC 27ti99=1636
S Method of kit•ct eri rc' mtti•�P>n) • • 24C.Fur Water 8tmn � '
�S • also
s ieeHon Wepr• kn addition' wit iDg the form to.
13b.Disinfection type: HTh 1 D p�0 /� �e (�)above, alsju submit'one copy of this form within 30 days.of
Amount: 170Z; completion of well construction to rile county health depaib6eat of the ccmmty .
. where constnteted,
• Form GWd • •
North Caroline.Dcpathaeat:off EariroamcdtelQaaliiy-DOisionof Water Resourcs ; Rei, .
•
_ - vM lo_ema'
II