GW1-2021-03461_Well Construction - GW1_20210607

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WELL, RECORD(GW-11 For Iatemat Use Only:
1.Well Contractor Information:
Gary-Thompson 14:wATERTA)N83 .:
WallContraetorName F"M To: _ DESC8OwN
441$-A k-y S r-,
,VC well ConteoctorCa,N6eetiaaNamixr 15:00TERCASING :multhessedjvelLa ORLINBR HmLIe
Aqua DOI, Inc. . FItONI TO DIAM67EB CKIMs UATEWL
Company Name• 'L 57 R ,-5- hL 5 t) U
i6.DVNl;Rt:ASIAtGOR-TUBING doseihl -
2.Well Construction Permitil: I L-t�3'-(.�t_l\gg-61 t, �Z. 16 n TO DL1B9Sl8t Tffit
List all appllcabk urll axWr artmr permffs(Le,WC.Cmmpt Stom Uartanee,ety & R !n.
3.Well Use(check well me): ID
1FB0 ; DL1bIElBlt _.. . .
Nato Supply Well: 11=81M M
Agricultural �MtmittipaVPubfic R. tL lo.
CWthemtal(Heating/Cooling Supply) Wesidential Water•Supply(single) ft.. ft.
IndustiaUCamtnaciaf ElRaidermal Wale•Supply(sbared) <Y&GROUT:,
Iai tint 1< bIATERM F1L f:66mW1MRnWD&AUOU=
Non-Water Supply Well:, d & '2. f tcm o I :•�. c/
dI
Monitoring Recovery fa tZ '
ajectioa Well:
AgnifwRecharge C)GroundwaWRemediation R
Aquifer Storage and Recovery [3Salntity Barrier 1F9MSANDJGRTvEL4ACt LM
Aquifer Test DSWnnwater Drainage
Experimental Technology [3Subsidence Control ft &
Geoffiermal(ClosedLoop) 3Tnu 20DRILLINGLOG addttiobelatteetsif
Geothermal(Heo oolingRetu n Other( lain underlr2l Remarlm) Faonr ro DMMOlfft sbm.em
`-
4.Date Wells)Completed: S`3`'a-L Wen ID# 2?S ft (�1b ; 5v l a
Sa..NellLacatiom Gh R' tit.L
Fact7ity/OavnerNamo Fmift M#(ifappliaabie) R
- - 77�1 �11ar-�l.�.r�y �:.s-�A�,�s Po:N•� CGi�e,.a��o r` ft. -- '•�
Physleal Add—e City ondZip w C try 5 j ft. fL
' r 21-REMARKS
county Parcel idendSWtion Na(PIM
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: O"BSgl11g
(ifweU field.one latilongissofficimt) 22.Certification
3G6 IZ'L{7 .2�44( N 7 ! a'T� YC. `7
6.Is(am)the welloo manent or Temporary S; of ed Well Contractor Date
i
By sipft dds famr,I hereby—V that PC uarli(s)im(ware)eonorao d.to accardmuz
7.Is this a repair to an existing well: Oyes or RrNo ullh!SA NCAC 02C.0100 or 1sq,11►CAC 02C.02W WeffCamvwdon&maim*ami that a
Ifthis l:a repa/r,ftUoM Aaortsr,mll omtrtraq/on hrformatfoti arrd eacplabr'the rmrmr oJdre eopyofdds.rW, has brvipnn,1dLFdm,dx4rell mover.
repa&wxkr 021 nwvAraer 0-or an the bwkgfddsf*rm 23.Site diagram or additional well details:
&For Geoprobe/DPT or Close&Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction.only LOW-1 is needed. Indicate TOTAL NUMBER of wells construction details• You may also attach additional pages ifne.cemw--_
drilled: SUBMfITAL Ih`STRUCTTONS
9.Total well depth below land sarlhec: - 5�-� (�) 24a For All Walls: Submit this form within 30 days of completion of well
IormrJdple,reilslisralldeptluiJdjBemrt(oomph-3®2fD'and2Q100� construction to the following:
I&Static water level below top of casi0g: (ft) Division of Water Resources.Information Processing Unit,
fftwer lewf irabm eatIA&use"T" 1617 Mail Service Center,Raleigh,NC 276991617
11.Borehole diameter. GD -On-) 24b.For Iniectlou Wells: in addition to saaft the form to the address in 24a
U.Well construction method: c-o� c-�► J�'� above.also submit one copy of this form'within 30 days of completion of well
construction to the following: C
(i a aaS ,rmmy,cdA,_dumptub,em)
Divislon of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WEU.S ONLY: 1636 Mail Service Centel,Raleigh,NC 27699-1636
-M Yield(gpm) Method of test: tif-NI +'r^a 24P-For Water Soonty&Injection Welts: In addition to-sending the form to
1_ e o the address(es)above, also submit one copy of this tbnn within 30 days of
13b.Disinfection type: "`�(^ d Amount: G - completion of well construction to theE county health department of the county
where constructed.
Form GW 1 North Carolina Department ofEuviro mental Quality-DirWon of Mrster Renutns Revised 2-22 2016
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