GW1--04670_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD D( W4.' For Wand Use Only; i
•
1.Weil Contractor lfuformatio®:
e2iy.Thomp or1 • ;
Wall CanttmctaPName PRODS TO'. . D iLSt nON f
44
• 1 A 40 ft' i•tc► cr144-,•�a.-? I%D (,pv+r"
.IC Well ContmcmeCacdfientionN®ber i D S- 0 ft Cr 4ac -.: 'l.i z. r,t ir`•
IS:O1tT1ti�CA$lt�lta(faY'mnllt (}S92t19)®1tI.1Nt:lQtifA'1tM111C - .`. °:'
Aqua Dri Fg 1, Inc. . • •PROM TO DIAttETFR THICKNESS'. WIATaIAL
Corn any Mato• • D ft; (IT ( .5 in. 5,)R • ,�`g,
16:�IWSR CASING Oi1 TtUR1PIG Cgeatbelrnal closed IMorP':::,. •':•.:., ':_:...
2.Well Constrncfion Pernilt#: 3 33 PROM DIAar a Tit a�, ,
List all applicable mil eottstractionpcmats(i.e.INC.Couruy,State.Varianed ate) ft. ft. In.
3.tR/e11 Use(checltwell use): ft. flu In. •
-
I
Supply weil: 1'scRLilnt. .. c , .•
FROM TO
DliflilErER si.4>;ssl� 78lCffiYESS •
arATER1 .
cultural unfeipal/Publie fa it. la.hermal(Heating/Cooling Supply) esidential Water Supply(single)
strial/Commercial �tieaidential Water Supply(shared) aw aaRolrr..
tion trAOnt TO nrArrcarer. Eitrel Acett�taytusnroD�laarotavrater SupplyWell^ tit t� gtaring �Reeoveiy R it.oa.Weil:ferItecharge iiGraundwaterRemediatiorI�SAptRvLPACfaim )ferStorageeadReeovery �SalinityBarrier FROM To MATERIAL, ifer Test �iStormwaterDrautegefL ft.
- •
-E1.perimentalTechnology �SubsideaeeCantrol tZ ft.
Ge0Ulennel(C►osedLoop) Tracer 20.DR�LIlVGH.OG(aemchaddtsaaolsGeetsifnecessor£�
'•Geothermal(Heating/Cooling Return) BOther(explain under#21 Remarks) soar To DFscRrParorrtmto,taaaoea,soma,ass re�r�gran etGt
fr. lb f' ClOy - _
A.Date Wells)Completed: 6-5-1 Well IDS lb ft- 9/7 fa 00—V Ski..(t"( Si.v�‘/ SOS
fin.Well Lucatlonl: ! ft. 0!S f' Cie/s►a({ Y l ` .
.�)ra.1 lc) .4oSkAwt ?laR. 535a Gro.A.c_
t-i •,
Faelityl0 timer Namo (`�•Facility lD4(ifapplirable) ft. ffi _ ' r� �t''Jt
•I()t-r Na4+^--�cQ, II.G111)L..r }vL7.�b 5b ft. (�!! g �/^► 1
Physical Addreee.City.rmdZip I ft. fr.
�JL .d Y CU�J
•
&VDIf. :S z1.REliQARI4S Is:�r-)-i 7rr.,.:. .:-[ U!n0
County Parcel id:adfieatim No.(PIN) DWCJ3'
- Sit.Latitude and longitude inalegrees/minutes/secondsordecimal degrees: 1
await field.one latRong is sufficient) �jA it Certification:
41;D -2- M► "1'0e N l{t%o 14I I.% 14 1i W . a
41.!._,... i • S 7-23
6.Is(are)the welf(s) ermaeeat or Temporary Signature fCettifie4We Ccntrsetor Data
By signing this farm,!hereby ccrrify that the vdl(s)was&e e)avnsttrtciedfa accordance
7.1s this a repair to an existing well: DYes or Ea< with 15,1 NCAC 02C.0100 or15ANCACO2C.0200 Wel1Cmtstrsetion Standards and that a - •
Phis t&a main fill out imam wall wmrruales Information medecplabi the owe ofdta ep1'ojtw recond hag been prowirtaIteUrna e►icwngn
malratder02l r atarfasection aran tltebwfcuf hfsfomt.
23 Site diagram or additioual well details:
. &For Geoprobc/DPT or Closed-Leap Geothermal Welts having the same You may use the back of this page to provide additional%vett site details or well
consttuction,only 1.GW 1 is needed.Indicate TOTAL NUMBER ofwells• construction details.You may also attach additional pagesifnecessaty..
drilled: SUgtytrrrAL INSTRUCTIONS •
C.
9.Total well depth below laud surface; ' s (it:) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells listolldeptltsifdffe ent(esampfe-3@200'and2@lao) construction to the tbllowing
10.Static water level below top of casing: �'a (ft.) Division of Water Resources,Information Processing Unit,
lfuteterlawlisabaeeaslnn sue..^ 16171vlal Service Center,Raleigh,NC276991617
•
IL Borehole diameter: (O en.) 26b.For Iniee..Pon Wells: In addition to sending the form to the address in 24a
•
above,also submit one copy of this fans within 30 days of completion of well
. 12.Well construction method: Celt-pt-.t1 Ai' -construction to the following
(i.e.auger,new.cable,daectpush.etc)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) method of test c.i.k-.t k'a n-e.- Vie.For Water Saintly&Infection Wells: In addition to sending the form to
• the address(as)above,also submit one copy of this form within 30 days of
.13b.Disinfection type: •k�C!�`010 Amount; 1( "Yt.- completion of well construction to the county health department of the county
where constructed.
FcmtGVl•1 Nail aDapa ref En nniantid Qua Division of WaterRenouscos Revised2-22.2016