GW1-2021-02308_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD(GW 11 For btemal Use Only.
1.Weil Contractor Eutbrmallow
J GaN-Thompson
tveuCoanaetortVame ram TO.. DBSCB)FRION
4418 A & & \
VC We1lConaonhnrCmdamtionNi®bar
• I6:011TBR. aYcttiernedwmt3s LnVSR� .."IteaWe�`� .•.•.-... :...
Aqua Dnll, Inc. . ant
peyN © t" I q j ft. C. W. \
�1 ,0 y 16I1RCAsnvGOR.74rBn�IcId WMAI
2.Well Construction Permit#: To J INZAAKIRTIM
fwaUopplrmbla,mlloanstracttonp Srontvaromere,) ft. ` fL
3.Well Use(ehwk well user „ ' 10.
1M _ ..
WatrxSnppiy WdL• ... : .::.. :. :. .. . .:... ..:. ..... ... �:. ..> :.
7LI
TO DD1bIE1Y3R 6LOTAecultwal n0itapel/Pub1tC IResidMiai Water Supply(single) f` ter.
IndustriallCommercial 0Itesidential Water•Supply(steered) 18.GROUT
:. ..:; ..
Iri lion on AIATERMss>p >he��.tnromsr
Non-Water Supply Well:, t R
Monitoring RecO R ft.
action. .
uifer f�II)G RA
I►9 �Gm Remmdiatioa ­FR SA
19. PBLPACg
Aquifer Storage and Recovery Sal' Hamer
Aquifer Test 0StorrowaterDrainage f ft
Experimental Technology 13Subsidenoe Control ft. it;
Geothermal(Closed Loop) 13Tmtxr 20.DB17.LING Lila attedt addtdoaat abeets tf
Gemtltermai(Heating/Cooling Ream) -Other( lain under#21 Iternmlm sltonr TO Iffourdleabbi
fa 20&
4.Date Well(s)Comple :��I Well MM Q
5n.Well Locadom -? R q6ft
Fao,0100. N. Facility IDli(ifopplitxblo) t<T..
rr� t-io
•�felrl� 11 P(�r(� ittt
1 ft [,. .
l�y¢[�`cntAddmcc.C�1y. drip ft •1L e.� �1
Aln z1.RBMAR[ffi
County Pmeel Identification No.(PIN)
56.Latitude and lothgitnda to ttegm'ees/mtnntes/seconds or decimal degrees: e,
� �r
rfaell Said,one Moog is suffident) 22.Certlitcattow
���r (��
o 09' N�U° � \.��qco W
6.Is(am)the weu(sj6Permauent or 13Te6porm si efC Wen Contractor Date
7.Is this a �'stgnhrg jb I hereby eerr&dmr the udt(s)I=(mery aonsanded to amordanee
repair to an existing wa: Yes or [dNo with ISA NCAC 02C.0I00 or ISA NCACO2C.02a0 WdI Cmr&won S7w*n$and thpra
((Ihie tratepah;Jlll eutkrohtrr�refl tammnadonlnjomwrknarrd esplaln7heno0me 9f►he eopyojd s recardharbeea pvWdedm dm tadlmrnen
ropofrrmdarA?I reomrlieshredon oron rhebaokojthbrjomr 23.Site diagram or additional well detans:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction.only I.GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional page ifnecessary. .
drilled CC SUBMITTAL 1NSTRUCITONS
9 Total well depth below land surface: �J (ft:) 24L For All Wails: Submit this forma within 30 days of completion of wen
Rornuftle�retls![dolldepOsijd�e�rr(esamT/e-3(a�2a��D•,,.ar��rd2(a�100� constriction to the following:
iR Static waterlevel below top of casing: J (ft) Divlston of Water Resources,information Processing Unit.
IjmvterlerrJlrabareassln&ass- 1617 Mail Service Centel,
Raleigh,NC 27699-1617
1L Borehole diameter._ (im.) 24b.For Iniectiou Weil_: In addition to sending the form to the address in 24a
above,also submit one copy of this foim within 30 days of completion of well
12.Well construction method: ABC construction to the following:
C+m�.�74 ea61e,d'aeotp>csh,etc)
Dtviston of Water Resources,Undergrotmd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Centai,Raleigh,NC 27699-106
•13a.Yield(gpm) I M Method of best: _� Me.For Water SuRuly&Infection Wells: In addition to.sending the form to
�
.�� the address(as)above also submit one copy of this lbrm within 30 days of
.13b.Disiniteetion type: AMA`A� g l �:o Amonot: 613& completion of wen construction to the°county health department of the county
where constructed.
Form GW I North oraft Depa mint ofSawronmeatw Qua!w-mrision of Wert.Resotacs i Revlred 2,22�016
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