GW1--02939_Well Construction - GW1_20240513

WELL CONSTRUCTION RECORD GW 1 ;Print Form.;
For Inteinal Use Only. —
1.Well Contractor Information: •
Gary Thompson .
14.wATERzo
Well ContraotarNamc `= I
PROM TO DESCRIPTION _ .. .
4416-A 6OOn' 68( 1
're. '6T i� •M
NC Well Contractor Certification Number ft. I 1
Aqua Drill,Inc 1S:.OUTERCASING ormulfi:cased.wens oRL -, ; edible. . _
FROM TO D,AMETER THICKNESS
Compan Nauio ® 61 m 644 " MATERIAL
2.We11ConstruclioRPermet#: -1'�W aMMINERCASINGOR SOti � _ PVG
TUBING' ::t 1111 doseit�tno i
List all applicable riell construction pennits(i.e.UIC,County State,Variance etc) ft. B t F,1u i� T> MATERIAL
3.Well Use(check well use): • 8.
Water Supply Well:
FROM TO
ricultural , Municipal/Public • D Ear stets ttucrcNEss'
' MATERIAL
11 Ag
*•Geothermal(Heatjng/Cooling Supply) Residential Water Sly sine ft. iu.-
Iw hldustriaVCommeloial upp Y( P'1) it. ft. Is.
Residential Water Supply(shared)
ii
fire y:lion 18:.GROUT _ -_. _' .
Non-Water Supply Well: PROM To MATERIAL _
0 ft• 2d ft $,+tta •t to"Pr"cs`"-wrdternoD&AMOUNT
I- enirereng Recovery e 'ovr t t1yCi?4�?
I Mien Well: _ ft. •
II uLfer Recharge °Gm etn
RDdwatrn Redeation U' R '
III'' . ','r Storage and Recovery SAND1QtTO PACE
®ISabnitYBarrier PROM to -_- �� -•..: : •.: ., _
*!Aquifer'Test DStormwater Drainage ft. MATERIAL SMH ACENIENT du�raoD
tr Experimental Technology E3Subsidence Control
ill Geothermal(Closed Loop) Tamer
20.DRILLINGLOG wadi ad&Onetat sheets d
l I Geothermal(Heating/CrmbngR rum) nOlhcr(eaplaanmder#21 Remarks) PROM TO DESCRIPTION{dra�.�mdc .-
�1"21.eTa,de)
4.Date Wells)Completed:S-1.2 4 Well ID# S b Qv d �°�aV
sR.Well Location: >z co tk
S.b ft. 61 'Belot t re►ritA e
Clmianiiti .,g br e�+sboso 1a.S a . 0 - a
Facibty/Owner Name FacDisyIDO(ifapplicable) ft.
•
!Wilt NG huh, IA Re‘atvIVE
Physical Addt%s,City,and rip �l�p�® .0 ir 5. ,�' I
Roc �n 1naa�n 'I°I bboo 4193 b5 9
Ce�v - Y' 1.21' t _
Parcel ldemifiwtion No.(PIN)
Sb.Latitude and longitude in - - '''.
(dwell field,one lot/tong is sufficient) minutea/aeconds ordeuimaidegrees: 1 I. ._ , `. ''
ct+'
J 6 a CR y` a At/ zz.Certification:
N 1 4154 5®.o'i
+� W
,t�7
Per ,a nt or Temporary Signature ofC4d Well cnes' 1 �-�s a`'l
6.Is(are)the well s)
7.is this a repair[o au existing well: ®Yes or No By signing thiefonn•I hereby that the miffs)Herr(weir)eman /n acoorrlance PhisIsarepair,JllloutWatn/I ISANCAC0hasbe0orISAKCACO2C.0200 t ConmucllaaSYaadaniraaddrata
repair under#2/ i ebacko tfommlfon and explain the nature alike "P1'old+nrnni7ras�rProvidedlo 4he ei 11 owner
rim* area rhebackojtlttsfona.
8.For oMlDPT or 4Rosei-Lao23.Site diagram or additional well details:
p Geothermal Wells having the mine You may use the back of this
construction,only 1 OW-1 is needed. Indicate TOTAL page to ch eddit onal pug well site details or well
drilled:______________ NUMBER of wells construction details. Yon may also attach additoDal pages if necessary.
9 TotalweU �eeL+7 SUB MITTA INcrDtttCTIONS .
depth below hwd surface: ��) .
For multiple wells list all depths tjaerent(sample-3(0200'and 2®A10') 24a.For All Weil: Submit this form within 30
construction to the following: I. daof completion of well
10.Static water l b level below top of easing: 60
y"�tic above use p (ft.) Division of Water Resou rces,Information Processing Unit,
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699.1617
Cam) 24b:For if ectlon Wells: ID addition
12.Well construction method: to sending the form to the address in 24a •
R rY '� above,also submit one copy of this form within 30 CLe•�,rotary:cables direct push,etc.) Y censhuetion.to the following days of completion.of well
FOR WATER SUPPLY WELLS ONLY: Division of Water Reso uvice Undearg aleig Iq C 276 Control P '+m,
13tL Yield(gpr� i 1y A lft'36 Mail Service Ce ,Nideigdh,NC 27699-1636
�p•ig Method of mesh rtdi'�G�►+'dome 24e.�tor Water Sanely&Infection Wells: In addition to Sending the Sum to
li3b.Disinfection type: 1{� �(i��t: A��h O. the ad (es) eve, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county where constructed.
•
Form GW-1 North Carolina Dep
artment of Environmental Quality,-Division of Water Resources
Revised 2-22-2016