GW1-2021-00851_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For)Mattal Useonly:
1.Well Qmhaclor Infwmadom
Gary.Thompson N
wallcam wtbm
4418A '
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Aqua Drill, Inc. .CWA M.
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IL URURCA>mVG OA4
IWell Coeeuacdon Permltik -����
Lmadaankn*M.dmammlmpe.mu(te.rRC Cmgt Star.Ymtarat araJ A a r.
3.Wall Use(clowkwdl me): R fL rd
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4
flaatllmmal(HWI*Codmg fkIP*) D I Mmdwa WAWswPb'( - R a) R R In.
lodu*lahConmetciel QResidmuni Water supply(shsmd) ,IL
01hription ram TOA
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afainuesena
Stttntge and Recovery Dsnu dy Beier 7A F
Uft Tau 13stamustarmaims, R R
Teftology 13Subsidemecontrol f, I R
Geothermal(Closed Loop) QTreaer -2L DRUAJN i
Om.6mmd(HathfaCoWn Rama) nothw(ceonoundert2l Rmnmly) taoat to
a It. a c
4.Date Well(3)Completed: {Q ) Well lD# o R a
5a.Well Lmdom R L_ Z n• Crn,, :
frtz]L',. .O.�Sr� �Fves Z a IYs ft.
Ftm'IirylOwor am n ^ LL P-1hy IDS(tfapplicable) it R
ft ft
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caamy Prcd identification No.MM .•
5b.Latitude and ptnglmde in tltgreedm(anteshecoods or dadmd dgteen
Orwou add.am h nsas is maieim) 22.Cerdlicetioa:
7�r° 20 ']?5-�74- N '�Xd't, A/6, 1 y Yl W
3 -t�%--i l
&12(sre)Ibe wou(s Permmt or O7'emporary 4ta�a ,wan eaaw Dr
7.Is this a �� AY divnsa d**x;t haver c-0 elm As,--ft am Nvn!cemaa:bd Alacwnbm
repair to an etdfdq wall: ©Yet err [.town rah ISA ACM dX.0100 or N AC 02C.0200 Met CausemonrStmiorb awdma
gdrkal.I - J111"knic..ra6avevaCAm tYlrsbrramda¢dnb deraaue s�the aaPy njtbs mra.ddot dtmporNdbbetndr oamr.
raa►.wdr121 ream6amsm ors.Air Amk,Vd6Jbtb• 33.Sift diagram or addiHunei well deaalls:
. L For GeoprWnMff or Clesed-laap Gesdxrmd wells haft do same You may use the back of this page to provide additional weft site daler'Is or wall
amhttedm,only 4OWlismedd. Iadf—TOTALNUMMofiveth constructlandwall, Youmayahommehaddidmipagaifaaaemy.
dolled
9.Taal wall depth below Wet arfaee I--d S ills) 1tla Far All w.oc Submit this Nam within 30 of
Faraadnp/e.nr4latalldapdut(d(1Rae,t femRk-3®tee'rd7®10a•) construction to the tbllowing �' completion of wall
It Static water level below top of cadog (R) Dividen of Water Resources,Information Processing Unit.
4'rae.bodradrve4Wv&am--- 1617 DUB Service Center,Raleigh,NC 27M-1617
11.1for"e diametar. (o (fa) Ub.For Iaiee fim Wells: In addition to seadittg the fate to the address in 24a
above,also submit one copy of Nis form within 30 drys of complemn of well
12 Wall mtlon method-. '(' A; / construction to the following
Cu.togq nary,esbt4 dfmerpadc attJ
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources.Underground Injection Control Program,
1636 Mail Service Cater,RaWgh,NC 2709-1636
Ma.Yield(gpm) 7 Metkod of test 24&For Wum•Soudv&Inaction Wefts: In aaBdmo to emdktg the form to
the addmKas) abovA also sobmb con copy of this Nam w dw 30 days of
13b.Wdafeedoo type: kt� elA Amount: 16�/� completion of well construction to the comfy health depm4vau of the couay
whereconsbucted.
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