GW1--05974_Well Construction - GW1_20230912

�/lE�Hr(t:®FT�' �I(C`�1i®IV RECORD t< �J�1y'�'Pi � • ..ito 6itkorm• •
�orinternalUseOaly. i ;
1.Well Contractor In ormatiom:
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'Gary.`Thompson . . {
WailCewagarName Ia•W FL+RaONBS•:' ..'.C'••
441�A • • t "°' ' 7 a- aor. Za
rah
NC Well CoatmetarCeatdseasontdember i +� i
Aqua Drill, Ingo :• . . .
IS:OUTER cA±i fh�molti:cased.Walia DELI MER.Mt Ilea'mon _ D • TDiC[W MA
Company Name• • fL Si f• CtIS in. Tla.'MATERIAL
r� • 1G.RVNCsRCAfiIl�iGOR•17JJiIA1G( 'tbcrmaldaseifaonZi vc
2.Well Construction Permit€t Q �..i • nr :• ••'
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btstallappllcablauYUcroruaueuan Drantm� IIOCs ' '`
pemtits(La.tl!C.Cow%Stara Variance,etrl { f6MATERIAL
3.Well Use(check well use): j re. . f aa.
Water Supply Well:
•Agrfeultt,tal :ieipal/FubliC E T DTATriLSseEI•m SLOSSIZ£ .TaIcee S .8..
Geothermal(Heating/Cooling Supply) '':.•�Water Supply(single) tt:• ft, to.
Residential water Supply(shared) .! ••g�GROitT'.;trfgatfan rout. ,. - ..
Non--Water Supply Well: �CeamNTt+�ttoD&A1UotAVT
ronitorin8 ; b ft: Zb ..4 :1:.
Recovery fs ...4.
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Zgiection.Well; fi:' e q )g
AquiferRecha►ge EjGroundwaterRemediatioa '
quifer Storage and Recovery QSelinityBader I9 •sANDlGRpVEygpciC,fa 6le
mtonr m �r,wzat_sittvrnan
AquiferTest OStotmwaterDminege fa '
Experimental Technology DSubsidenceControl £p_Geothdotnal(Closed Loop) Tracer • {'
apt G( ig athi ment oLo amiaow*eats ifnec ari:
ot
Geotheanal(Heating/Caolins Return) nailer(explain under#21 Remarks) Emu " ar scturrcoxtmtar t®aae,,sow,ock„�L , ,mot ft.f ��' C,(a ,4.Date Well(s)Completed:cS_(5=).3 Well MU •
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5a,lYellLaeati •o £c 7 £d: b>, � 5�- / Sal •
c- C1 tdik('`De''r. S. f6 "3�Sf ,
Facility/Owne?Ffaeao �re9:v� 'tit.
Facility MO(ifapplieabla) 1 R. St.
5-7 Lw. TO Li ciOU IA(4- .P4 Tob�ctr �►IIQ j ;� E. 4
Physical Address.aty.Ga As (NL g a® ®il..I I D
corky I 2I.111044Rfcs .. . '. :•,:: SEC 1_ 2 1323
County Pwreot Identification No.(PiN)
' 5b.Latitude and langltndeln•degrees/minutaJsecondsor decimal d gees: t�f"•~"''`�' 7404�'T U
(ifwel!field.ono tatllaogissutrcient) ' G Rt!`t°�1'�}'
22.Certificationt
01 z' 5.3 icPil-r03P,I fit'c'° ram..' S<C. 451/14"w
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-1Ce"-Z�
6.Is(are)the wdU(s) •eruaae>at or�Tdemptneary •Sipuene•fC, ' ed Well Con Data
By signing Iles form,1 bercby certify that the tre11(s)uvs(urea)eonsauaedla accatdance
7.1s this a repair toan egging well: DYes or Bag pith HSANCACOIC.Ol00or1SANCACO2C•0100 Well Construction Stwrdatds and tta,a •
phis isanepatr../iU out Ionia wen conuractlonb onuatlanandetpkfrithermnnedike 'cropyofdtsrwadhas bean Molded inMamdlmrrm •
rcpafr fader 021 remarkssealon Gran the baekoftbtfenn. j
23.Site diagram or additional well dvrraitq',
ti.For GcoprobcIDltT or Closed--Loop Geothermal Wells having the same You may use the back ofthis page to provide additional well site details or well
construction,only t.GW 1 is welded Indicate TOTALNUM131Ri oftivelts• construction details.You may also attach additional pages ifnecessary:.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ' 2.4a.For All Welta Submit this fern within 30
For multiple tsatis flu all depths ijdijerent(eoomple-3 ' dMOW) ( ) , days of completion of well
canstructiontotitefollowinlr i
10.Static water level below top of casing: ii D (ft.) I Division of Water Resources,Information Processing Unit,
Ijunterled et is chore°'°&use
1 1617Ib7ar7 Service Center,Etalelgh,NC 27699 2617
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11.Borehole diameter. 6 (in) 2db.For Inieee on Wells: In addition to sealing the form to the address in 24a
lb Well d onstraction method: /a Fw r t ' above;also submit one copy of this form within 30 days of completion of well
(is:au=mom,cable.diueetposb.ere) construction to the following:
Division of Water Resources,Underground Injection Cow Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC27699-1636
13a.1 field(gyro) Lb Method fittest c tal'cl�1•P'r`Vr' ' 24c.For'Water Sunnis&Infection Wells: {In'addition to sending the form to
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�-`,�c1 D vl the addresses)above,also submit One copy, of this form within 30 days of
.13b.Disinfection type: 'p Amount: l (D /►t_ completion of well contraction to the county iealth department of tho county
where constructed. .
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Fenn GVl•l Nonh Carolina Depatameatofa:vuonmeoi d Quality-Division°Motor Resources Revised2-224016