GW1--01837_Well Construction - GW1_20240322

•
LL CONS U O CORD GR►_i L •PrintForm,
For Internal Use Only.. • .
:1.:Well Contractor Infbni adon: . •
Gary Thompson.' I .
• 11.WATElZO1Vi�.
Well Cantrector Name. • •
FADM TO ni�catarsoM .
'4418-A' . • • - • - . 1tioR7 ta.$ rdurar . .! tj tseyl
NC We11Cdn1edorCirfitietimNamber. :d' R
Ataue Drill,Inc • 1s.ourlaiCASOIG(fwntauk. wriTe)OR LINER Of ier
rtwai • ' . TO nuarErrrR THICKNESS •MATRRw.
C .: •Name • • •b• f.I'.lI.D tt.�)'.L..1;'I>:-,.5-O.a../%: ,e l.L.: '. .
• CoDitr. . •Peraii• . Nib' • .?:p I W ER CASIINGOR'MEDIC(Readmit,!ao.etNeste.. •2.Weu p t ' 64-5. ._PROM To: •
•ld isdIapplicablei902e�l riFilon 'DIAMETER- 7> 1... MATERIAL
l..rnla(r.�urC cow►h�.srara'yo►ra!Rar,a�� . . tt' . . • -.ft* ' tn.
3.Well gee( CtRweu riser •• • • • • • �. . . .
Water Supply Welb •17.tlCRRFZ4'
•MI Agricultnal Pmai • TO . ..' DiAMCrBR BLOTai�'�u IlPablia. R: la. rnicaftesa , MATERIAL '
1 Peathen:id(liiatmg/Cooliog Soppy) : identiel Water Supply(P1*) . fft.: . •' : ... C.- : ' ' .
OResidential Water Su pJ (shaied). ' 1g,GROUT ImiQ,tion , . . .
FROM 70 • ' MATERIAL
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. Sb.Lafltade and longitude In clegreesfinlnutentsecondior decline!'
- ' •(ifwell field,Oita letllong ia,ufgcieno. • 8'r[�� `s In E:Z
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.1...it ii n D 22 CertiBeatlott• • u6 r`ldi
6.Is(are)tttewreg(s)1erenaaent .or. .Staanaeof ed We Mee.
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.Temporary' �/!� CoutracDo:• Date, .
4y 8107264 Mg:km;t h1 (nw++)oonrtiricted fm mtoniance
.7 le rids a repair to an eslettng well ••DYes. dr, • :rho!Ike will())Kite
(fthft isage,alr 101 in tibtoan►t�epconstnictbn +I ��Co2Ckbeen100 or, NCAme iwa OO R'eUConrductiaei.5llandm�r m�d1yat o
1Rfaforix.ande4plafntheerieim.oJtlre • �P1'4�thlarrnwiilFasbun,mvldedtn7heiwlloisvier' .
+epafra�r42i 4F21 rartmitaeoeflonaroathebaekyf6Lefler,:.
• 23:Si a diigr4m or additions!wen details: '
•if:For.GeoprobNDPT Or Cdoaedj lop Geothermal Wells hiving the Mini - Yagmay Ruse:the bade of tlila gaga to
eonstmctioa,onlyl•OW 1.is needed.'IRidicate TOTAL NUMBER of wells - aanstruction detaiis.Yen Pm+dde anal pageaaa's if ecet ialdetail('1or• .
•
drlllcdt titry also idtaahadditioaei pages if neceasuy,
• .svab41TTAx.IrisyatrcuuoNg
9:TetalwsA depth bawl land a!>rtlee;• .:•� •'�? _ -
FbrAaduple trelb.ustal1*Phi U'd{�mt(Raan,le-d®200'mzd 920Nj.' (ft•) 24a.For All Welke •Submit thia1 form.wilds 30 days.of completion.of.well
cenahuctiontothefn•lloiving.
10.Sheila*stet lend below:tep orm ill*: 5j5.
(lxnr�tevel is at er I e aorGiA one�+^ (tL) ••Didelon of Water Resmere,•Information Proewigg halt,
• - '1617 Mall Siren Center;.Raleigh,-NC 27699-161T-
. 1LBoreholediameter_ �. N•)
:12.Weil conahDcHati Wells:. s
24b.Fir.Intecttan .In addition to sanding the form to the addres in24a
• *eft.
= r o+y'.,r tr : 1i,'e , e> 0.'also salt Oita 114;of Phi.loud within 30 days of completimR of well. '-pa augeer,Rotaw,esble,dheitpm6,eta.). . conat iclion to the follawmg I I
!PR WATER SUPPLY WELLS ONLY:•_ • . • DitdtloD of Waterlteaourea;iJndergrommd Injection Caatrtel
�' •1636Mall Service Eontar,Raleigh,NC 27699-1636
a 13 .Ylela a in) t D.. Memaaorte u,�t-�:L. 4!e�.... . I
• 24c.. r water soDDirr&tiiediait_Welta.In.addition to sending the laud to
•
13b, eHaR type:._1 i.H 1. f�lq.Amount( %. of i t as ve,-aloe man ro a Copy
of.this.loon.Within o the,
days of'
f aemty health deraAateat afahe.dowdy.
.. where cxnatacud...
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•NmthCuolfnaDapaMmentofFnvhomaeatel
. . QmGtY-Dlvie[oriofWeterttcwmeca. Reviscd24Z,2016