GW1-2021-00286_Well Construction - GW1_20210127

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WELL.CONSTRUCTION RECORD(GW-1) For lntemal Use only;
L Well Contractor Information:
Gary.ThompSOn 14MATERZONES -
FROM 70 F: DESCR PI
Woll Contractor Name - - , �• fb 7� ft �p�
4418-A
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IC wall CanuaawcerdfieetimNUAW 16.OtrM—CASING :mitlthenstdwdt4 OR LINER' eahte:`
Aqua DOI, Inc. . - TO 3) ffi t
Comparry Name• C7 ft rE R (,r) in. 7�� �'� 1 V ��u�
16.INNER CASIIVG 7.:
2.Well Conrotr cdon Permits.. Lq o�b CN�l N --)—b FROM TO I DInt3IE M F ntATERia
List aft appffeabfe rrc0 owwraatfon penofis(Le.WC Cowry,Store,Vmtwm%Per-) tL ft In.
ek 3.Well Use{che well use): tt IO'7
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Water Supply Well: .175SCR8EN.... ,1 ::' • ,.:, .. '`FROM" TO DHlMEM SIAT81ZE Tffi . ..
Agricultuwl 0Munfcipal/Pubiie it: iG fo. I ,
Geothermal(Heating/Cooling Supply) Csidential Water Supply(single) R �,
lndmstrialiCotnmercial OResidentiat water Supply(shared) <3&GROUT.,
[Aquifer
on FROM MATERiAL F�mlPLA tiiE1HOD�Au DtsT
ter Supply Well:. fL ft.
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Storage and Recovery [3Salir*Barrier FROSMANDAGR�vF�i.PACK;MATERInt.
r Test 0Stotm "wDrainage fL fL
ental Technology [3Subsidence Control ft R
rmal(ClosedLoop) Tracer 20.DRILLINGLOGattaehaddidobalsheeisifum*wrvFROM TOrmal(Heating/Cooli Realm) - Other( lain under#21 Remarks f� ft. I M
4.Date Well(s)Completed: (�)3"�1 Well ID# 1,1 ft. d $'
StL Weil Location: fLL kLA4 `S o
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Pbyskd Address. :andZip C, L11S3
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'2L REMARKS
Cmmty Pineal identification No.(P1M
5b.Latitude and longitude in mhtutes/secondsor decimal d rnst!on '�ioccls_no Uni
Gftvei Gold.one lat/lonns is safidew ZL Certification: D V V 1 7,1:3
W.
6.Is(am)the well(s)0ermament or DTemporary si of eel Well Canthator Date
By sfgrdng dds form,I hereby eertffy drat rite twH(s)1—(errs)eoradaavd In otaotdmra
7.Is this a repair to an eldsting Q well: Yes or To. idth ISA NCAC 02C.0100 or 13AMC 02C.0200 Wdl Comondon&mw**and that o
'*&isa mpdr,Jllfamh mm uwfl co Ion hrfororafka ad cWkiYtheMaim ofdte roirygfdds recardhas been prwkfed to the trdf omrer.
,vpvbrwu eru21 rcmanlssec A oron rhabackgfddsform 23 Site diagram or additional well details:
8.For GeoprobdDPT or Closed-Loop Geothermal Wells having the same You may use the back of this pegs to provide additional well site details or well
corist ruction,only 1.OW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessery. .
drilled: _ SUBMITTAL INSTRUCTIONS
9.Total;well depth below land surface; "7 S (�) 24a. For All Wells: Submit this form within 30 days of completion of well
Formnhlple irdk fisrall dgWn ifdi8eml(=ample-3®2W'arrd 2@1001 construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources,information Processing Unit,
ifanrerlerd fs above C"I%we 1617 Mall Service Center,Raleigh,NC 276991617
IL Borehole diameter: (inj 24b.For Infection Wells: In addition to sending the form to the address in 24a
11 Well constr clion method: r�64 t* above,also submit one copy of this farm within 30 days of completion of well
r construction to the following: .
(ie,auk salary,cable,daectpmb,ete�
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a..Yield(gpm) 3 Method of test:L+hkL-A-`h.G "24L For Water Snooty&Iniection Welts= 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:k� `� Amount: l 6,� completion of well construction to the county health department of the county
where constructed.
From OW-1 North Cneguit Depammem ofEuvironmental Quality-Division ofltrater Resomm Revised 2-22 2016