GW1-2021-04312_Well Construction - GW1_20210419

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M I.I.CONSTRUCTION RECORD(G1.1) For Intemal Use a OW.
L Well Contractor Intbrmadoti:
Gary.Thompson wAT$R : :.. . . : . . . ..::. .
wall Connector Name t?R W W. D
4418-Ar�-
-a_�a�
NC WoQConhmtorCesdHeaHenNemlea
O 1� B .N � ORLIlVSR ....IImi►1e 11a alfel we1R
Aqua DdII, Inc. . 4a
Company Name• tt 1 5 le' SORB V u c
I6.IICBNG R CASGiG OR-TUBING' ... :.:..
2.Weil Construction Penult& Oat TO D nyn�lu: '
Im all apalleablowtu movedonpenahs(Le.U1C Com y State vananca etej ft. ft. "
3.Well Use(Check well user R
Water3applyWdt: .. . .: ..... ... .,.. .,: •.:• ..
FaOat TO rABlS1ffit trL01'um T�
Agricultural OM -eipaisublic. fa tw In.
Geothermal(Heatinycooling Supply) 5Q. ential Weber Supply(single) ft:. ft la.
lndust&VCommetcW DResidential Water Supply(shared) ..-I&GROAT
Irk lion RROXI RIAMMruanton�..
Non-Water Supply Wdh. v tt & (�
okrC s
Monitoring Recovery R
oyection.W t:
f6 ft
Aquiferltedwge E]GroundwaterRemediotioa .19..sANa1GRAVi+,I.PACIfi
quifer Storage and Recovery Salinity Barrier FROM
CID
Aquifer Test 13StotmwaterDminage ft &
ExperimentalTedmology 13SubsidenceControl R ft.Geothermal(ClosedLoop) E37racer 20.DRELLiNGLOG addch l.addidau dheeaff .
Geothermal(HeatittglCooling Return) Other( lam wrder#21 Remarim) FROM TO Dssauerdord
R• &r.
4.Date Well(s)Completed: Well MN % &
5a.We11 Location r.
Red eccn 1/Aty �,s e N '� IL
F¢iioility/OOwneerNamo Facility lD#(ifappGcabto) ft ft
1(" l o mac- '4wy ��� �Awajtti1 2`rD�(/ ft &
PtrystedAddrtux.C.tty.and25p r `C R
S-I-p k Sys 21.RSMARKS
County Pineal idemi6cadon No.O ON
5b.Latitude and longitude in degreadminutestseeonds or dedmal degrees:
(tfwea field,an ladleng is satRdent)
22. tcotioa
Zro'ySS�- N b0 (fir° �1�. ��'6 V{I �ii�:,i{�.3i�,^•tl� ..
u;.
+;Vr`.
6.15(am)the wells ermanent or DTemporory Sigoatore OFCGKW14 Well Caneaemr Date
7.Is this a repair•to an ealsting welli es or ®No BY dgdng ddsfOD°t hereby certify a-die writ(s)Ina draoy conrttuared[aaoaotdana
tr/th 15A NCACO2C.0100ar15ANCACO2CAM iYeffComovedonS/aadatriswd dial
Ifddrtsamptr.jV@ufbmmtrelleon&uW=kifonnattonamle:WlM,tAceanaeafdhe wpyofddsneeordhorbeenpmeldedtodtetrellowner.
.aparrander r121,em Arsecdat open the backofAteform. 23.Site diagram or additional well detalist
L For GeoprobdDPT or Qased4.00p Geothermal Wells having the same You may use the beck of this page to provide additional well site deals or well
cortstructioa,only I.OW-1 is needed. Indicate TOTAL NUMBER ofwelis construction detarls You may also atmch addiiond pages ifnecemy- .
dulled: SUBMITTAL MSTRUCTIONS
R5�o,�hco..� 1L�
9.Total well depth below land satfacc.•e'y (�) 24a.For All Walls: Submit this form within 30 days of completion of well
i or amtdpte wdk lin all daps a O djobint(buzurle-3@20D•and.2@1601 construction to the following:
It Static water level below top of ces)og: .a (ft) Division of Water Resources,Information Processing Unit,
lfanterlew1 traboveearing.are"_" 1617 Mall Service Center,Raleigh,NC 27699"1617
1L Borehole diameter•. 6 (in.) 24L For Infeetion Wells: In addition to sending the form to the address in 24a
IZ Well construction method: above.also submit one copy of this form within 30 days of completion of well
(i a a romty.cable;am ere)
construction to the following:
age.
FOR WATER SUPPLY WELLS ONLY Division of Water Resources,Undergrauud Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
•13a Yield(gpm) Method of test: 24c.For Water Suaniv&Injection Welter In addition to.sending the fort to
h 7 D ` the address(es)above; also submit one copy of this form within 30 days of
.13b.Disiutbetion.type: % Amount: I /i completion of well construction to thei county health department of the county
where constructed.
• I
FetmGW 1 NonhCarolcmDepanmentof8wironmemalgmliw-I) ismnof-WaterItactu es Ravised30,2016