GW1-2021-01846_Well Construction - GW1_20210503

STU CONSTRU ZON RECORD U 11 For Internal Use Only:
' I
i.Wen Contractor h ormatioo:
GaN-Thompson
%VollContmworName F"M To: I DIM
44.18-A 9 s ft
& 06
aC WeU CoatinemeCmdHeetien Nionber M-OUTldtCA s'ING fir*ao[eldxaied
Aqua Drill, Inc. . mum I
comparwNtane• Ti % it, fo,a�' In: , SbRa-� _P Ue-
16 RMER OR•TU m
2.Well Construction Permit&_ab'1plYagp(e.j o»I 'm D
Lcu ell applftatblatiadl eoasnaerfonpemrt[a(Le(!!C Camryt SranL Variance era) ft ft. Lft.
3.Well Use(eheckwell use): R ft,
WatarSupplY Well 1z'scREEN::. .. .: :...•• -..• ..: ,':_. •..
FROM TO DIABIErn aLOT81Jl
Agdcultuntl rmicipaUPublic. h qt, ta.
Geothermai(Heating/Cooling Supply) Optesidentiai Water Supply(single) ft. f6 In.
lndush ietecommeccial 13Restdmww Water Supply(shared) IL GROUT..
73hrigation FRoaiM MATERULauF a>Blgaaa<
Non-Water Supply Well:. fi ft �
itorin . r v� r?c.rG�.,
Mon
s Recovery ft. ft.
Zu eeAoo.
- ft ft.
Aquiferited a lle 130roundwaWltemedistion '
Aquifer Storage and Rees -9 SAND/GRAVELPACK'
t'ery Selh*Barrier O
�
JAquifer Test OStotmwsta Drainage ft. ft.
Technology Subsidence Control ft. fL
Geothermal(ClosedLoop) 13Tracer 29Dl JM(;L,OGhWihnddidunalstesatsif
Geotheal(HeathWCooling Retum) 01her( lam under#21 Remarim) r(toht 'co asst stox tar
rm
ft. l Sr ft.
4.Date Wcil(s)Completed:�`1�`'2t Well M11 7 a S)-W J =
So.Well Location: 13 & IL 5o u
FaeilitylOwnerNanw Faciliw11"(Irfopplieoblo) kl ft 1�1r` Crr ri `r
u(a -�a, 1 Y_v R4 (a,-s r s c- 1 e)1 ft.
p� 4.'0.
•^(pfW Addeees,Cdy,and ft. •fL
NU ! 21.RBDIARM
v
County Parcel Identificadon No.(PIN) l�
Sh.Latitude and longitude to degreWminutes/secowb or decimal degrees: s811��
(rfwellfteld,one le angUsdffdem) 22.Certlticatian: �����It�3tc�rV��E JrO{►
3S S4t o V k3 " N [D� S�ISS��' r' W
6.h(are)the wellwalkrmanent or OTe;mporary Sfoaffore ofueniffe4well Contruta, Dace
By sfV ft deft form 1 hereby ea*dmr the Irdt(s)war OmV corumovd In accordance
7.Is this a repair to an existing well: JoYes or Ito rrfdr]SA NCAC 02C.0100or iSAMC 02c.02o0 Well CownedonStartdar*w d rhar a
((Ihts trarapafr.�fll owMocrn ueU nlnforararlonared e�lata'tbaaatwe gfrhe wlW ofdthxeordhas been providedtodu iodl owner.
t,rpatrrmderr321 rvsmrdtsrxdoa oroa thebaaEafddsforta 23.Site diagram or additional Well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this pogo to provide additional well site details or well
construction.only LOW-1 is needed. Indicate TOTAL NUMBER ofwells construction details.-You may also attach additional page ifnecessary. .
drilled• SUBMITTAL I NSTRUCPIONS
9.Total well depth below land surface; a-�' (�) 241L For All Wells: Submit this form within 30 days of completion of wall
Forarrdilple rra14l1Na/l dePdesrdf�emr►(emtuple-3®10D'aad2(a�100�
construction to thefollowing:
I&Static water level below top of casing: � (ft.) Dlvisloa of Water Rewwses,!taformatioa Processing Unit,
[/timra lerr/rrodaveaartn&use^-" 1617 Mail Service Center;Raleigh,NC 27699-1617
I Borehole diameter. (in.) 24b.For Inieetioq Welts: In addition to sending the fort to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: r o h�1 1� r construction to the following: `!
(&A aw.-my,esm%direct pud,•ate)
Diviston of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Ralelgly NC 27699-1636
-13a.Yield(gpm) Method of test: CA4zj_j Y!►✓t e, Zoe.For Water-Sunoly 8c Injection Wells: in addition to sending the fomr to
b of p ft addres(es)above, also submit one copy of this farm within 30 days of
.13b.Disin(tection type: r9 Amount: L �� completion of-,%vfl construction to the county health department of the county
where constructed.
�u
Pam GW 1 North Ca Vo a Depn==t of fimironmewd Qualib-Division ofNata Rsomees Revised 22'1.2016