GW1-2021-01004_Well Construction - GW1_20210419

WELL CONSTRUMON RECORD(�1) For IatemalUse Only.
L Well Cattractor Information:
Gary.Thompsn 114L. qW
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Aqua Dail[, Inc. . > om 7 . NATANA
CompatryName• d ft. f fL Gi-�-S' W S eta t r
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2.Well Construction Permit*__���-I��`1 FROM TO DI&BIErnt I TRUMUM I tni►TERL4
List alJapplteabla enslloonsrrncrlmrpermlts(Le U1C Cmnrq,Stota t/ar/ane�ere,► & R ln.
3.Well Use(eheek well use): R % hs.
Watar Supply Well: N
17.'SCRI3BN:O : ,,...
Agiicuitmal eipallPublio. � � auaasren sLOT
Geothermal(Heding/Cooling Supply) entiel Water Snppiy(ogle) fL ft la.
btdustriallCommenciai DResident m Water Supply(shared) FL GROAT.Irrigation on AUTINUAL t=atr E1B—&AUOt=
Non--Water Supply Well:, ft a R f ref el : 5
- monitoring Dam—yery ft ft '
Zoe oo. 1:
AgUiferiteduttge DGroundwaterRemediation ' tZ
quitter Storage and Recovery �Saliady Barrier FRO T PACK-
Aquifer Test [)Stotmwater Drainap ft
Experimental Tedmology Subsidence Control ft tt
Geothermal(Closed Loop) �Tracd :2L DRILLING LOG aWch eddtdohat sheets w
Gtetdtetmai(Heating/Cooling Return) r-3011ter(explain amder#21 Relmerlm FROM TO affi
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4.Date Weil(s)Completed: -� "�`t Well mofLi as e
go."well Location. v'
ReiIItylOwnwName ( J Fac*k IDS ifooffelble)
-19 1 D L i rp 1'I�C/� .IF YJ WA f�i¢��i t�N lid 1 ft ft
Pdyctenl Addcecs,City.and2ip
ft fL
county Parcel Udenri6earion No.ff" a
Sb.Latitude and longitude in dege txslmiauteslseconds or decimal degrees: r y
(Mvell field,one Mang is safctent) 2L Certification:
i--I•' A4 7 -24k"4'u N � be f M ,S-3Ze W
6-Is(are)the weU(sji;ermaueut or DT'mporory Si OrAft e,tveII Cantraetor Deco
By sfVft difs fom,1 hereby we duo die udl( sros(,,,V to warmed fn aaaordanee
7.Is this a repair to an existing well: Dyes or O No w1*15A NCAC OIC.0100 or 15ANCAC 02C.0200 Nell COUMIWOnSYmtilards and dra1 a
#'*k Is a nWair.fiff wd km rn wdl courra MW b&wift and cwthin-ftraran v,,fdL- eopyefdetr race rdhar bow pmIdedtodras411owner.
nvvirwdder$21 mrarkrawgon or an dheha*gfftform. 23.Site diagram or additional well defolls:
8.For Geoprobe/DPT or Closed4mp Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1.GW 1 Is needed. Indicate TOTAL NUMBER ofwelis construction detatk You may also each additional pages ifnecessmy. .
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: fn) 248. For All Walls: Submit this form within 30 days of completion of ,all
Forum►dplewifthrralldepdesffdjemn(aompfe-3@2tD•and2@1005 construction to the following:
K Static water level below top of casiow (ft) Division of Water Resources.Information Processing Unit,
lfmoter lerllsaboveeorii z.are"-' 1617 MR Service Center,Raleigh,NC 270.9,1617
IL Borehole diameter: 6 (in.) 24b.For Iniectlou Wells: In addition to sending the form to the address in 24a
11 Well construction method: r 4-m.1/ A i, above,also submit one copy of this form within 30 days of completion of well
CIA saga:marry,eabte:di mpus%etc)
construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
•I3a.Yleld(gpm) a Method of best: 24c.For Water Spne v&iniection Wells: To addition to.sending the form to
the addresses)above, also submit one copy of this form within 30 days of
.13b.Diduf etion type: )j4k7D% Amount: 1 %a. _ completion of well construction to thei county"health department of the county
where constructed.
FatmGW 1 North CatoftDq-umtafSttviroameatalt.thy-DivisionaftVaterRe mere Rft*ed2,22,2016