GW1-2021-00306_Well Construction - GW1_20210127

Prirgt Form
WELL CONSTRUCTION RECORD(GWV 1) For haerned Use Otty:
I.Well Contractor Information: — -�
David L. Hardy, Jr. 14.WATER ZONLS
Well ComegmNuoe FRM TO DESCRIP71011
2906-A R -
R = n NC WellCamaaor CadDphim Number
Aqua Drill, Inc. I&OUMrASMG tbr.rdrmawab to=MMOMM
m 7rl DIAam7Hl sYT®W.
CaDymy Nevx A ///
L West Construction Permit 0- I_%I C /o (%V ]C FROM
CASMG OUT
7O mA1QIt7l WA7IDAL
llwdl appl/mb(e ydl touovcrimPamra Re UfC,Caymx Stair,t'arkwa ae) R R
3.Wall Use(check well use): R I R tat.
Water Supply Well: 17.SCRLEII
NATIONAL
Agricultural [3Mwicipel/Public 0 R R 4
Gmthermai(lieukng/Cooling Supply) JoRewdenriei Water Supply(a4,)
/Commerdw R R la
lndustrial
DRetihkntal Water Supply(thahed)
m la 7o
Non-Water Supply Weil. R
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PGwffiM1U1J
ing Recovery R R
Weil: IRM
B.
�Le D(hauhdwaterRrmediaim Storage,and Recovery I��mar Pam 7o aATZE&LTag QStormweoer Drainage R Rmeul Technology DSubtidemeaComrd RRmal(Closed Loop) DTtear X DR11"VG eati od' Redmn Otto lam Roder 021 Renharks 1O ..1twA
C Date Wells)Completed: f''J 2 ' Weil ID# R R
Sat.Well Location:
i
FeNiry/O.rarN®e 7C
Phyanl Addrtu.Gry.=#25p R R
e/'S L ' ) ✓� �D 2i.REMABI�
County - Peed ldmafw No.(PIN)
51L La#tmk and longitude in deLredndantet/xeoadt er decimal degrees:
(ifaell fu4d,owe Imams is mRcrat)
_ n / Q 22f tron: ( J
C N C� U—55 7
i h W
(m)the 2 must or DTwmpoin ry Sigmilum afCarfified WeD C DAN
7.Is this a repair to an tabs we& BY elur)h m,1111e�'of �'M aloe"MA)e a(yae)ommaer id he awowdm,x
Ifddrtra DYa or BNe vrak15A ACfC D2C.alDp or lyA ACAC OLC.SM WtU Come came�derdread otmu
npair,JWam ka+rs rdlmmoay,wr l wm000wadepla,M hmome of,be eopyofddrremdhm besepmvdedw Ae wtuoxiw.
repair adv 421 nsosrkserom ormi des bark ofalc,ev v
n n F Site diagram or AdditionalweN details:
8.For GeoproWDPT or Cloned-Loop GcolOermal Wets havi '1hs se�ua ?J`You may use the beck as this page to provide addiGmd weR site details or visit
aDBDoction,only 1 GW-1 is needed, Indicate TOTAL MUMBLE of wells construction dtlsDs. You may also attach aWkimal pages if necessary
drilled: SUBMITTAL MUMUMM
l
S.Toml weBw depth below had q,,,( (fL) 24a. Far AR Ytb Submit this form within 30 drys of completion of well
Far sm/ap(e well:4o all&par yeOTe+rat IewosrpJe-3(�200'ad]®Idd')
omuDhhccou to the following
I&SlIde Water lewd
inI(umaeewlis above�Wow,lop of casing: 11 (B.) Divhlom of Water Resources,
tapratloa lerveemMg unit;
m`yam- 1617 MOM Service Cussv,RAlelgh,NC 2765l-1617
11.Borehole diameter. /p.) 24b.For Inlacdon Wan In addition to sending ten form to the address 24a
IL Wen mmatrned"amhW: X �(�.'— above,Also submit one copy of this fa®within 30 drys of completion of wall
(ia ails,Fanny.sable,dmxt posh,ate.) emnt[tu:Uah te sloe following:
FOR WATER SUPPLY WELLS ONLY: Divhba of Water Resources,Underground Weedo s Control Program,
1636 Mail Service Custer,Raleigh,NC 2709-1636
13s.Yield(gpm) glie(hsd of tear -1 2&Per Water Snooty 8 ahetlea ffj& In addition to sendmS the form to
yJ — Ill the addee*cs) above, also submit me: copy of this form within 30 days of
13b.llbimfeetum type:_,C.L__ Ammmt 1,6 ,4 amyledm of wall comtruetm to the county health department of the county
wMe caesttnsc[d.
Fora GW-I North Carolina Department ofEmmonmaW
Quality-Division of WaterRosomoes Rarird 2-21-2a16