GW1-2021-01624_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD(GW 11 For Intemal Use Only.
L Well Contractor Information:
GaN-Thompson 114L.WATER
NaUContr¢aorNaarc F60M m: n n.
4418-A IL F�AL��!� 3 b Gp»,
ft �
NC Well cm►asaooeCeetlaeetienNi®6ae
15:OUTSRCASDVG ft►htt[uidxmedwdio) LINER " 90'bW : ::. ..
Aqua Drill, Inc. . D
CompowName• ® R ell R' �. :/51 G A i✓
Ili.IIc➢ciBR CAb'>riG OR•TiJBING .
2.Well Construction Permit#: b � (�vF t..N ` hi DrAh1lTFR
L►ar all app►reWc tmgeansrmaenpermas(Le WC Cormp3 state Vance ere fL b6
3.Well Use(check wen use): IL
Water Supply Weil: 17:8CRRRN::. .. ..: .: :...'. - :.:.:.. •..:..: :::;.:;. ;:.. .:::
FROM TO DIAB1ttiTliR
Agricultural o)paUPublie. ft. gt, ia.
Geothermal(HeWmalCoo1mg Supply) IGf prtiel Water Supply(single) ft.. R
lndustriel/Commemial DResidentiai Water Supply(soared) 3S.GROUT.. ;. :.
"Iftigation FROM hL► . W MMOD&' OtMr
Von--Water Supply Well:. C7 S R
Monitoring R= }�
ecdoa.
fG tt
IA.
quiferRecharge E3GroundwaterRemedietion ' -
quifer Storage and Recovery nSelinity Barrier FROM �►vEL PAC¢
on
uifer Test StotmwaterDrainae ft: &
perimental Technology OSubsidence Control ft. tteothermal(Closed Loop) [3Tnmw :2L DRILLING LOG addeh additional cheats tfeothemmal(Hesting/Cooling Retum) 001her(arplain under#21 Reme FROhr TO DESCaUMMI
n c a ' dA
4.Date Well(s)Completed:3 LJ Weli m# lA a &
So..WellLomtIon: 2D & ly D• c cJL 'S1oy.rD �,
/-tea wt es �F o 4( 6 ra .Viz:
FderlitylOwnerNome pwiliw MAI(ifapplica6le) 45r R' 1y/5 to
�l 3�l rysSc+air.�QJ�r[—iJK+►+$�f�1C%3�.b Gc'1a{�h7,nw„f,. fL % .
PBycient A*hac.C4.aadZip r` R
21.
i
Ceuety FW=I identification No.ON
5L Latitude and longitude in degrees/minutes/seeonds or decimal degrees:
(Ewalt geld.am Mont;to=fflcieat) 22.CertMentlon:
'35655'd'X9 14,Cb� N `796'S'A:Zy 724V W
6.h(are)the weli(s) ermaneut or DTemporary Sivaturipffeewsefivell Connector DDto
7.Is this a repair to an existing well: Yes or o BY s►�dtb farm'I hereby ear 0*0 rue tmll(s)wo(Ir"eamoaared rh a=r&m
,dth ISA NCACOSC.0100 er l5A NCAC 02C.tt20 WeNConwmdon&amf rds and dXl o
(/ddsrsa xpatr fHl eutlaohsr rre11 oxatracrPoatnformat erplarn'rherroaue o1 the eopyefd s—rdhwbem pmWded m dxirdl oawen
,a/mtrrarderr721,eamriramenmrarea rhebaotojrmajo m 23.Site tllagrom or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
won,only I.M-1 is needed. Indicate TOTAL NUMBER ofwelis construction details You may also attach additional pollee ifnecemy. .
dulled: SUBMITTAL INSTRUCTIONS
9 Total well depth below land sorfatee f (R) 24a.For All Wells: Submit this form within 30 days of completion of well
rarnudilple nelk linallAWde ifdffibvu(esrarple-3®200•aad2@1001) construction to the mowing:
it Static water level below top of easing: Division of Water Resources,'Informatioa Processing Ua%
ljmmerlmrl traboveeartn&are"_~ 1617 ail Service Center;Raleigh,NC 27699-1617
L
1L Borehole diameter. 24b.For Intectloo Wells: in addition to sending the form to the address in 24a
M Well construction method:' ro4-ttr� 9Q ✓ abovk also submit one copy of[his tbnn within 30 days of completion of well
fie.eager'.rotary,cable;di>eetpush.ate)
construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center;Raleigh,NC 27699-1636
133.Yleld(gpm) 3 6 Method of test: 24e.For Water Snoniv&Injection We1L In addition to.sendiag the form to
c the address above, also abo also submit one copy of this fbnn within 30 days of
.13b.Did fbation type: >'i'N17° Amount: << /Z completion of well construction to the i otlety health department of the county
where constructed. i
FmmGW-1 N"Coraft DeportnatoffindromimidQwIiW-DWbionoftlrawRomm-s Revteod2412.2016