GW1-2021-01631_Well Construction - GW1_20210430

WnL CON�CT'ION R1 CORD( 11 For barrial Use Only
1.Well Contractor inatrmadon:
Gary•Thompson -- W TEsZON .;:;
j$
44�18-A 3� .
well eamraetorrtame > ,n:
64C wen Coatraamrcardou*mtJumbw
IS:OUMICASDVG tUr�tUeased:tvdta ORLIIdBR aside `
Aqua Dn{{, Inc. . D
CompmryNeme• R �o �$ tu.
16.nvN$RCnsnvGOR-wenvG :;::.:, .:.:•.. :-.:.. ,
3.Well Condruedon Permit#: '� FROM I To uATEuML
List all opplraoala:rrUoon:nncnonpe maa ice WC Ce".Siatm vmrnnm ory ft. %
&Well Use(check well use): R R
stet supply Welt: Mont TO DIAb1hT8R Enron..
LAgncuml umcipailPubiic. ft yw tn.
al(HeltiogfCooling Supply) tar W Water Supply(Single) ft. ft, in.
Wbrometcial Residential Water Supply(shared) 1&GROUT�w To AMIMMAkANOtn�rr
Non-Water Supply Well:" -0 ft Z ft �( n
- Monito. Recovery ft ft "
veetion. : ft ft
AgbiferRechmV 13GmundwaterRemed edon
Bugg
quifer Storage and Recovery [35olinity Barrier 19oM TO
A1VD/GRAt►2LPACg 61e
Aquifer Test 0StormwaterDrainage ft ft
Experimental Technology 13Subsideneo Control ft ft.
Geothermal(Closed Loop) Tracer :2L DR)LLING LOG aWi h addhlobd dn�if
Geothermal(Heating/Cooling Rem) DOffier(eylain under#21 Remerlm) i FRohr To aEs
C, & l� ft. aid C.fw
4.Date WIN)Completed: welt mo a tt ft g6;
SL Well Location p 2ti ft CC
C-u:► Q,r I yv�t,s L A W c f, ft.
Fhaility/0araer Name 1D0(ifappnaa6la) �S D• 2 2� G gyp,
L�la SIGH LArve 6 f-k a 2c el g_ �..�. G�a)+a» Ne- ft ft �,.
Pbycicd ty,and2ip _y.�2. tt ft. .,,,
County Pmcai Idendfieation No.MM •
51a Latitude and longitude is degroadminutes/seconds or decimal degrees: t
Ofwell gold.one Mug Isanftialenel ir;#�r►�;:���Lf
22.Certlficatioic 'On
3✓�Sis ?Sl _G74" •�N W*17 Q% t6l W �L"J�
6.Is(are}Wcwdl(s) ermeaeat or OTempOrary Signs ofC' ' eQwell Contaistor Data
By dvft drtr fomt,1 herrby osrtffy der the irdl(#ue r(ImV oansovemd/n a=nlmtee
7.1s this a repair to an etdsting well: OYes Or NO with ISA ACAC 02C.0100 or ISANCAC 02C.0200 Wdl CmaoraWon&w*njr=d drat o "
{/ddrtsarepair, lout6tmrncmllomurrurtfonlnJi►rmaUonmede�►nfn"theuaamofrhe tWofdelsreeordhasbeenprwddedtodm:adiomner.
wpa&un&r#21 remsnkswfian open daboskgrdlsfomi
23.Site diagram or additional well details:
L For GeoprobdDPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
tmnstrrmcdoa,only 4 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details You may also attach additional page ifnecessa0
drilled: SUBMITTAL INSTR;iI:TI IM
9.Total well depth below land anrface: a-2 [ft:) 24a. For All Wells: Submit this fbmt within 30 days of completion of well
r-nmldplemdb;itrtatidapdrsfjdffenw(araarpie-3®2W'and2®1007 construction to the following:
I&Static tvaterlevel below top of casing: L D (R) Division of Water Resources,Information Processing Unit,
!ranter level&aboveeodn&axe-" 1617 Mail Service Center,Raleigh;NC 27699/617
11.Borehole diameter: C (in.) 24L For Infection Wells: In addition to sending the form to the address in 24a
iZ Well construction method: r4"bl dr► / _ above,also submit one copy of this form within 30 days of completion of well
r- �.�doectrn%ate.) — construction to the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center;Raleigh,NC 276991636
f
13a.Yield(gpm) ) D Method of test: rtrI C. 24L For Water Snaaly&Injection Wells: In addition to sendfag the fort to
the addresses)above,"also submit one'copy of this form within 30 days of
13b.Disinfection type: -,+L,l a Amount: 1 C22.
completion of well construction to the county health department of the courtly
where constructed.
FommGW i North Carolina Depatuestoffimrltonmental Quality-Division of%vewResources Revked2a2-2016