GW1-2021-04244_Well Construction - GW1_20210419

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VARUJ OH-8,T MON RECORD(�-I) For 10smal Use 0lil3r
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1.Well Contractor Information-
Gary-Thompson wA
tYal Cotmaete IVeme FRObt 1M.. I DISCROPM111!
ft ft
NC wan CoaumorCmNBaatienNeml= 15.OUTBR-C:AA8II7G .alnitT�rasedR ED
IZM ` "Dm6ie
Aqua Drill, Inc. . FR� D
CompWNeme• IL R `.r T. la.
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i6:UVNIItGASIIN(s OR•TUBING .
2.Well Construction Permil ff:L—t` U J P D.-W—ooG MGM ro a au.11CHIM '
Lw affopphoblo neflconsumdonpandO U fl/C.Cmmryi Staaf,Varmnra ere,) & (h ln:
3.Well Use(check well use): it &
17.'8CRSEN.. .
TO DiABm= BM
WatersuPPzywalL• :.. :, :. .. . ... ..... ... ,:. ..:
Agri PROM ft:ctdttual � tmieipaUFablie_ yl, to.
PGeothtmal(Heft'Coeling Supply) N 'dMiai water Supply(single) ft. tt 1. le.
industflaVCommercial DItesidentid water supply(shared) I&GROUT..
irrigation Fnonl HORK ODdk otn�rl
Non--Water Supply Well:. O,z„A,.;(t, CA I H
if
Monhtorm ? Recovery ft tL
Zaiection. &
AgWbrRecharge DGmundwaterRemediation 118ANDIGRAVELPAC[t ble
quifer Storage and Recovery [3Salinity Barrier FROM M
Aquifer Test [3StolmwaterDminage R ft
Experimental Tedmology C)Subsidenco Control & R
Geothermal(Closed Loop) Tracer 20.DRUJA qQ LOG aaaeh addidabd a ma W
Geothermal(Hesting/Cooling Return) Other( lain under#21 Remarks) FROM TO asscarartox for
c� iti i a & rep c_I a
4.Date Walls)Completed: 3-.!D`-)-k Well iD# ft n
Ss..Well Location: LI 52—
G„& 3z,5 ft.
FdalityroamerName 'Faality 1D#(ifappUwbta) ft ft:
1 LJ, i r (nutrl7eQ wc_ '11ID -X-1 ft ft
plryateal Add=wa City.andrip R A N
CEVjG�hrCtf�Arf ti ounty PmeolldeotifieatianN0.(PiN) Zt, ��.on�JZ!ion
Sb.Latitude and longitude io degra dminutes/seconds or decimal degrees:
(ifwell Held.an(Mang is aaffidew) 22.Certillcullon:
566 xS'03,-253-)t4 N 06
61 '0t4,`7,74;�,� W
6.h(ara)the Wa(safermanent or DTempor ary Sign ute ageeMANVell onhaetor Date
By stgamg dds form.!hereby dm(d+dmt the srelt(sj teas 6MV)eonsOuGed m a=rdame
7.Is this a repair to an abling wall: 13Yfx or �To with 13A NCAC 02C.0100 or 1SA MC 02C.0100 WdWour racdon S►m,dards and that o
fft irarepolhiV Ourlm m trall an nm*nbiformadonand aVaIn'th nanine offhe eW ofdrfs reeordhasbeen protWedtothe nril owner.
repa/rrmder d?1 rrmnnbmdon neon the baatofrhisform 23.Site diagram or additional well details:
L For GcoprobdDPT or Closed-Loop Geothermal wells having the same You may use the back of this page to provide additional well site deals or well
consttttttion,only L OW-1 is needed. Indicate TOTAL NUMBER of%vells construction detals You may also attach additional pages ifnetewasary .
dnlled SUBMITTAL INSTRUCTIONS
9.Total well depth below hard surfaec: �7 it) Ift for All W Submit this form within 30 days of completion of well
Fdrnuddple walk 119dl ddpda#*dff-m(cmmpfe-3®20*and.2@1001 construction to the following:
It Static water level below top of casing: �s✓ OL) Division of Water Resources;Information Processing Unit;
tfmarerlaellraba Oewng:are 1617 Mail Service Centp%Raleigh,NC 27699-1617
1L Borehole diameter- (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this font within 30 days of completion of iveil
12.Well construction method: rt k s-V A r ✓ construction to the following:
f+.e•sage,some!.cd*daeetpasb.eea-)
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Uudergrmmd Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
43a.Yleld(gpm) 3 Method of test: CA kkt �`�+�- Uc.For Water SuR&&Infection weus: In addition to.sending the form to
the address(es) above, also submit one copy of this form within 30 days of
.13b.Disin.f etloa type: -•D alb Amount: L completion of well construction to the county health department of the county
where constructed.
FWMGW l Moth tatolinDepmtmmtofEmimumeamlQuaft-Divhsionof% terRaomcrs Revbed2-22-2016