GW1--02726_Well Construction - GW1_20240507

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. . WELL CONSTRUCTION RECORD(GW j . - • • .
F or Internal Use Only
1 Well Conf actor Information:.
r nt Form i
Gary:Thompson '.:
Weil CantiaclorNanio
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' NC 1Nell taiahactorCertifirati•on Nsmber
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Aqua Du ll,Inc:: . ' - ORLINERtif
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Water sil.PPIY Went
Ageieultntal ': i • • :DIAMRTE7l
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t�ROM pro
Geothermal(Heath Coo
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usirlal/C ._. ' . � .. ._.. . .. to .. - ' .
s>� Tt9ICiQ�IBBS MATE91Ai.
ommetatal ,.. _ • .
Residential water supply(shalt d) la:GROi T _:
No -Wate Supply Well. .. 'RROM 'TO MATFIZiAL • .RIYIrLACplyiglTl'MEI'QODicAMOUNT
Maiitonng :.. , .: . :=_ E:i «r.•- b •rc. •ab f �� ps i e . - v i • -- M .. r e _• ..
: Aquifer.Recharge
• .. Gmnndwatioiegt© edietion
Aq rstoragendRecovery. • /GRAVEL.PACK(u■aadca6te) - .
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Gce�al(Reanng/CoolmgR¢imp)' '}Ohe texplein imder#21 Remails)' : io ettaci ad8 ( y_ f
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4:nave Wens)tt ompletede''�{ l wen IDS '��. •n, S y •Q d= C •eat .
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. •. . P6yaicat Address, ity.Imd Zip : . . - . . .
' .' Stakes: :. . .
' . • '. .. . 'Ei.REMARt;g
Cow -•.. • .Peiccl Ideatificahoa No:(PIN) .
. . • :.56.Latidlde cad[o fade to - .
:•(ifarell deli;o.s deeiera/mbiittesbeeonds or dedinol siogtrees: •' ' M •4•
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6.Is(ere)the we11(s o'.
or. . . Sig.na•17. Wall 1 . .: , . �• ' .
7 Ia this a sepals•'• eida well .® .
BY s/gntn�thGt fo»u,•!herby � '
Yee Or : '.: that the.020s):was' ' • •
r�trQder l fi.illoud or on• n expO ►salsas ojilra c°k!eft/Ns g'0' or/SAS he ve oaoa wear r a u:a' lain-!he .
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' 8:For • . - Z3;SIGs diagram or.atldlttonal infra' • . : ..L. GeoprobNDPT or Qosed-Loop.Geothermal Wells having the seine.• • Yon may ose the ba*of this paga,,D.pmvide additiaodl we11'sifa details or.well .
'. conetmction,only'1 G6p i is needed'Indicate TOTAL NUMBER efwalls ' suction details. you'pi*also Dune)oddili al pages
drilled .�. . .
Toldwen pm i lariatttlrraoe.: - • y _ : : ••.
. FiJH11fl'ITAL 1N57RUC170N3 j
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(�) necescmy,
For;qutnp►e wells fistal depths.Vd (maple j��'�z 16
••• 24a.• .For MI wefo wing••t • •••n within 30 days of completion ofwell• . . ® � aonstritcfionto the fiallowing: . � -
10.Static"wales lave]below to ofcii
p ahlg: .. SO-,:-. Of*. . .
lftwiaerlege[is abore use=+d ( ) D1v161ori irer Re�aices;Information
jj 1617 Mill Service Center,Raleigh,NC 2769971617..p
11.Boirehole.dbDteLer: KJ :. . (�) '. �' �_
' l n .-241i:For Xntectlen Webs: In edditlori to sending the form to the addtrss in.24a 12.:Well conatrntrtlini.-. : .. -R6 ta. (y A\!e - . '�.also submit one copy of this'fomt within 30.days of completion of well
(La aligns,mtmy,cabin,daect Pnsb.'ere) ' twnsuuedon-to.the followiii�
FOR WATER SUPPLY WELLS ONLY'• .- . .• Division of Water Resour es,Underground Injection Control Progreoi,, '
I A . : •.16"36 Mail Service Center,ltale3gh,NC 276991636'. • ' • '
18a•Yield(Spun .'Pia.
a'•': . Method of tes•t•l,Qi Cy.1°171 y"l 24e.Far Water Stipnly&-liilecHon WeUD: In edditiOOE.to
13b:lllsinfeetion type:_I4fi`k 1b°/b Am•oti : , // b • .the iddFes(es)'alio ro.Oho ubaut�one.copy of this:foim p tPiiii o'
A completion of well consttechen to the coinity health departm
. where
eat of the county .
Ain'tGW-I .. :
North Catnlinn Ucpattrncat ofBnviroitioeatat Qtiaiity=Dlvisiou of Water t3eso
tows
ReVrsod 2:22-2016