GW1--02153_Well Construction - GW1_20240409

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.,WELL coNTSTRUCTION RECORD.[GW-�,) 'Por Internal Use.Only {
.1.Well Contractor Information:
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.Gary Thompson. • I
14.WATER7 •.
ANES'- I' .i
WoU Coatractur!tie . FROM_ TO -DPdL'Rll?dON
-4418=A0`� 5a5 Fe�►e 'ot '306.(3t� .
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'NC Well ComnetoeCertiButIo ixunilici -
•• • 15.-OUTER CASING gbr mufkased Odle)OR LINER(if a licable) -
%Aqui Drill,Inc. FROM " TO DIAMETER t . THCKNESS - .MATERIAL .
co ria na O.--"IL. :.38... n- •.6e 5''!a.. Spit. ' •. PVC
• .16 IIUNERCABINGORTOI3INGloon tcrmaldanddoop) . •2.Wet:ConatnmJon Permit HI•'AVipliQ -Obi •• . FROM .TO-. "- Dimaimi n I • •.TDZCIOVEeS mama. ._ ..
flit all applcablestillcartina:t uspermlh(le.'UIG,CountyStateVarlanr4eta)• :.ti•• _ft:- . ;•In'
.3 Well-Use.(checkfulluse): R."
' Water Supply Well: 17.SCREEN I
FROM. TO • . . ".DIAMETER'• SLOTSIZE THICKNESS -MATERIAL-
19 Agnculhnel : cipaYPabllc:
' ti:-' •" .8: is
.ill Geothermal(Heating/.Cooling Supply)-'. Residential Watertft. - . I. •
Residential Water
>�lndttahial(co�ercial' �7. y(s .
. .' litigation - FROM - • TO" MATERIAL i : EMPLACgmerri HETHOD&AMOONr. '
.Non-Water Supply VCR: ' . -cov. tt. tt 8e fo9i'4•t;
iR Monitoring •• ' - _ ,� Po• lar. '+1•ydt.
Injection WeUt
91 Aquifc ecliarge !G
EDGmundwaterkin ediet on .
it.''Pifer' torugeand 19:SAND/GRAVEL PACK(ifarnllodOO
•..jSalindyBaaier .
E+RNI •TO • MATERIAL I . LACEMENTMETROD . -
I'AqulferTest •. . ,E StotmwaterDiniaage R $ i I, • - '
: it0 : Technology Snbsldrnce Control .. : R." - :fL • •
' 'thentnal(Closed Loop). I: ti • .20.DRILLING LOG(attathadditionel ahem inraanary) •- " _
Geothermal(Haatin7/CooiingReturn) fOtlur(explebimder Oil.Remmles) -z•ROM Tto• •
tZ: D t1oNt rrn+r,ah.ctcssvar 1112r,rtc4" ;
•4.DaEeWen(s).Cumpietea::3-33` 'HWef109 - • -. . -.j0 " . -33••--R. "- . •Sc\na4 Say i . . -�: _ , . . . .
•Sa.WellLimatioa: . - 33:'-It. •36 ,t: •- Gceane}e.- . " : . .
' m - Covr S .,. ... -38: ° •5MS a�- . (re w.P4g..
Faclity/OwmrNone. r. . • pFa OR)?lD#(if`oippileiNe): • " fG- I I R„
IAAS" h.1ty: c*t.W4 'Rf. R¢\is iati .a 3„itteC - " - !L tt:- ; •I Aa ._T. . R.a,
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'P6ysiedl Ad#,,n,citAand.z0:
•• pNR �, T. _2u24: . - .
Rockitn�han\ 21.REMARKB'
coigns,. . �l• . ..Parcctldentifcstto`i ta;onl) - - • !L. ~.,•G: _- .Pr- ii. •:y 1.):1'
6b.Latitddeaad ion tutte is - i;'e r=�'-
Bi do elminutes/seconds or,dedmvl degrees: .
'(ifwell field,ono ladlods is ao03eieat)- - " " . 2.Certlttpetlon:' • j'
36.35SA1, __ .N.- • lq.58t6yo. ,,, j
. . 6:Is(are):tite,we1(s) pern�Dent .or �Tesnptmrry • Simone of al, elios - - `" 2 _: ,
T..Ls this a re BP signing thir fonn,.Unrebymtg.p that the well(s)ueo(were)'conitraoteat In aceoidaaace.
1 Man eslatlng well QYes 'or•®No rvifh I5ANCAC 02C:0100 or.134 NCAC 02C:0200.•Well.Cenrauetlan,Stagdards'and Mai a. •
flaktaarapatr fill outhrowa%Oil caiuhaeaton brbrmat on aitd ezplain the natane edt.e;. mPP�I'th&rtsao hit beta,provtdedro"tail orvsen, !
iepair.ander#21.tentarlar noronthebaekrlfihitforim: . • �;.
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.23.:131te dfngeamor additional well detest • • •
• 8.For GeoprobeJDPT or Clored-Loop Geothermal Willa having the lame . Yon makuse the back of ibis page to picvide.additions'well ate details or well-
eonsttuction,only 1OW=li d,snreil. hidkit TOTALNi1NIBERofwells ' •Constnictiondetais.Yonmay.aLaoOnahaddnienalpagesIfaecesseryc.
drilled:•, " •
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BQRR1t7TAI,INSA R,UCTlONS•.
: vratalwenlbottibelathuidier[ace: -- .(tl:)• Ida.for.All Welke •Submit thisl.form`•within 30'da of c--
FlvremLlplewei/s7/ifalldepIkted18Rteat(exampit_S(d)Z00,and 201009•• . . 'days omplttion of iNeU
a •consdadion to the follovrlttgo- 1'
10.'Statleweter level belti*top of casing: • -•60 • •• (fit) Division of Water Resou
. ,y'wdterknit is abawecaike i se"+ rceJr RaleI a,NC 2 oce 4161 Unit,
• p 1617 Mull ServiceCent�r,Raleigh,"NC 27699.1617
11.Borehol dianietei:' " 6
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e���') 24b.j?or_7nlectlon Wells'In addition to.sending the fbim to the-eddrese in 24a"-'
•:12.Will censtrn¢tlon:gethod: • . lw`a1�' 'Nit
aback also submit one copy:of this'one within 30 hays of cotttpletion;of Well
'VA=FA rotary;mble,•Efaectjaim,sta.)• • consttuotion to'the following .
FOR WATER SUPPLY WELLS ONLY:: • - • Dlvlslon of.Water:33esorrees; ent argion i Ii gaidatt Contrel•Program,
r 1636 M. Service C ter,Bab gli,NC 27699-1636
'. 13L Yield „ ) ",050 • ..Met od often t'koI1 MTtl " •24c. or rater Sotto*&Inlecti`on Wells: In addition to
+j i: . N the Pays of
the.addte sending
136.D,',,,. ,an pie:. . -6• •Amount:_-- Ef..0111... . - Of above,.•Co,also•imi tO ;one copy health this.form•within:th days:of."
completion of well•eetntntch�to the county department of the.county-
whimcomtnicted: " . ('I!
.I+ormGW t. ileitis CmelinapcpitfnientofFavlmmneapl Quality-DfvirtoaofWeterRe
'Revised 2.2242016
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