GW1-2021-01005_Well Construction - GW1_20210419

Print Form:.
VMU CO1r 87RUC77ON RECORD(GW-1) ForimmalUst;OWN,
L Wen contractor information:
GaN-Thompson WATMZD
Ivan ConasetarNome 1aO 70., n wk
4418-A 2Y& -5i7 %
MC WA CoehnowrCadfi0WGRNi®ber ioS� �f G &
MOUTBR.CASIIVG ttiraYnht tmedwetis
Aqua Drill, Inc. . M
Company Name
-0 f I T5 ft G.X-.5' la. sou z.+ p uc
2.Well Construction Permit#: ��t7`�40 16:n+u�llietCAsnvGOR-7YTBIIVG clued
List aft oppikabla nsl/oonsuucdonpaum(te WC Comuy.Siam vaAanea are-) ft ta.
3.Well Use(Check well use): R & hL,
17c' ,..
WaterSapply Wdi: PBOat TO DraBn= I swum
Agricultural icipailPublic
Geothermal(Heatioscooling Supply) dattiai Water Supply(single) ft. ft te.
industttaWbinmercial OResidential Water Supply(shared)
73hrigation FROM MA & . OMfr
Non-Water Supply Well:. ft Z ft.
Monitoring Reco ft ft '
eefte
ft ft
Aqi»wReduup �GracmdwaterRemediation
Aquifer Storage and Recovery [3Selinity Harrier FRO AND/GRAVEL PACK'
Aquifer Test [)StormwaterDmimage ft fL
Expedme old Technology }3SubsidenceControl ft ft
Geothermal(Owed Loop) 13Tmcer Aeoftilnecavatry
Geothermal(Heating/Caolhng Rem) MOkber(explain underfk2l Remark-•;) -iZ ' TO ass
tS n
4.Date Wells)Completed:3_7 1 Well MM l ft. ft
� a
Sa.^WelellLocation. ft ft.5� ct+w�
/tip ALt;l6f fl. 1 s-46 fl, r �` c"- .
Faci fty/OwnerNamo raOW WO(ifoppftble) ft
tvL ��f o ft ft
PhYalml Addsacc.Cilq.aadTip ft % ,I
at- 4-G,�
sty
5b.Latitude and longitude in degreedinioutes/seconds or decimal degrees:
(ifwell Sold,one luflong is=Mdem)t 1 D ZL Certmendon:
33,-7aIr-r" W.
��ls zr
6.Were)the well(s)OPermanent or 014orary Si 4yZ4 o C tHed Wet entraewr Dew
� By sfgrt/ng dds form,I hereby—i&&w roe tmff(s)uar 6mV aomnuaed to aomrdwee
7.is'.his a repair to nn erdating well: E3Yes or 0 sdth Ise NCAC 02C.0100 or 1SANCAC 02C.0200 Iia#ConvmcdonShomwrdso d dlmr o .
j(UdsQatelmlr.JHlomAmnrnsralf�rmraafonfiformarknande�fa►n"rhenoltaeofilke copyofdihm odhwbcmpvWdedtothasrdloirner.
ravtrandarr121 re mrbsecdonoraathebaa4ofdkfam
23.Site diagram or additional well details:
L For GeoprobdM or Closed-Loop Geothermal Wells having the same You may use the back of this pogo to provide additional well site details or well
corwsnrction,only 1—OW-1 is needed. Indicate TOTAL NUMBER ofwells comtnRtion detaft You may also each additional page;ifnecessatl .
dulled: S MMrrTAL INSTRUMO YS
9.Total well depth below land sorfacc: fft) 24a For All Wells: Submit this foot within 30 days of completion of wall
/brnndtWe indis linalI depda trJffenan(ar-We-3®20D•and 2@1001 constuction to the following:
it Static water level below top of casing: 4 b (ft) Division of Water Resources,lafar'metion Processing Unit,
Ifenterleiri/saborecoins use•'+" 1617 Mail Service Center,Raleigh,NC27699-1617
1L Borehole diameter:j_(in.) 24b.For Inladk 3 Wails: In addition to sending the form to the address in 24a
12 Well construction method: r� a-y iv above,also submit one copy of this fomn within 30 days of completion of well
(M -my.calla;daectpas%etc)
construction to the following:
Division of Water Resources,Underground Ionjection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
•13a.Yield(gpm) a/�7— Iviethod of test: � � 24c.For Water SunnW&Infection Weller In addition to sendmg the form to
%
A `1 D the address ove address(es)ab ,'aiso submit one copy of this form within 30 days of
13b.Dislutbetioa type: Amount: completion of well construction to the county health department of the county
where constructed.
i
FomtGW-1 No liCadinaDepmamaotoMmronmentdQuoHly-Dwoonoflvate lie maes Rev6e112%U-2016