GW1-2021-00307_Well Construction - GW1_20210127

PflDt Form 1
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information; —
David L. Hardy, Jr. td.WATER ZONES
Wan Contractor Name FROM TO DPSCRWTM
2906-A R R
R R
NC Well Cooaactor Cntificatim Number IS.OUTER CASING for odti-rand west OR 1,Q�
Aqua Drill, Inc. aRDM ro . D �.
R R4 11f Ill
Company Name /� n ..`� 14 DINER CASING OR TUBDIG V
L well Construction Permit il: 2 L L / J 3 PROM TO DtAnRIII I MATERIAL
Lirrd1 appllmb/e well caraauctwo pe mtu ft..UIC,Corny.SaM v.,o,a,etc) R. R Ill
3.Well Use(check well use): R R 4
Water Supply Well; 17.SCREQI
FRAW
To DuatarER apre>a su
Agricultural OMunicipaVPubhc 0 R R b
Geothermal(Heating/CoolinS Supply) JoRe nden ial Water Supply(smgle)
R I R te.
IadustnaVCommmeial QResidentud Water Supply(shared) IL GROUT
1knitstuin FROM TO
Now-Water Supply Well- R- r7 /• �� �^
Mmitoring Rxovery R R
lajec on Wdl:
Aquifer Recharges O(houndawter Remediatim R R
U.SANMRAVEL PACK
oiler Sterage and Recovery 13Salinity Barrier PROM TO MATERIAL ARIAl30�rr METHOD
Aquifer Tau OStormwater Drainage R R
ExperimmW Technology OSubstdame Comrol R R.
M Geotmal(Closed loop) OTraeer 2a DRIXAMG LOG ameh.dtldapwl aheanaC
Geothermal(Nadi cad' Reaun) n0ther(m
plain under#21 Remarks) PROM
R
1 /� n ) IL
4.Date WtWs)Completed:y[.=-µell WO R R L a..
So.Well Lora 3eP R.
FmIdy/Owoor N7ame Faciity ION(if applicable) R R
5- // L'—A 7' // 6,q �/ l R R
Phymal Addrn+.C' d Zip 2 / 4f Z R R
21.REMARKS
Pamel Identification No.(PIN)
Sh.Latitude and lopgitilde is degreea/mieales/seconds or dedmal degrees:
(ifwell fiekl one liallo 1 is suffix ) 22. tioa: ,r�'/) J
N W G L ,
6.Wan)the well(s)QPa"oun ect or OT'emporary Si ofC '/ Watl Cmaactor /
.g By rtgrdng do,fbmt I luroo mrWy Wr.9(,0 pry(Wray)rouse wood N aamrciumc
7.Is this a ra pair b an ex6b wdl• Yes or QNo Wilk IJA NCAC 02C.0100 m 15A NCAC 02C'.0200 Well Cmanwcom S W vi,and don a
Ifdu,u a rrpWr.fll eon bewa Well rapaar Inf.m opines e6e aad,ofthe aayofthis me ,dhm been pm ddio&w ftowwr.
POP Matti,121,sans*,mom or m tat bd ofth,,form. 23.Site diagram or sddltloaal well details:
S.For GcepobeMPT or Cksxd-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed indicate TOTAL NUMBER of wills caDtruetion details. You may also attach additional page if netsaary.
drilled:
SUBMITTAL INSTRUCTIONS
f.Total well depth below land■orfact, R) For All Wails Submit this for within 30 of cum letion of well
F mdopk-1/1 tdldeplAr if&ffr t/e N# 3@2 'ed2®1001 m P
is �
� 'onto the following:
Ill.Settle water level be
low by �/� .'��' (ft) DMsiou of Water Resource,Iakraetios Prooasiog Unit,
ljwato kcal u abw nmA�uae•+-
1617 Meg Service Cate,Raklgh,NC 276"-1617
11.Borehole dtemeter. n) 24R For Isieedn■Weld: In addition to sending the farm to the address in 24a
12.Well censtrattlo t method: f) � �/ above,also submit one copy of this Tam within 30 days of compleion of well
(ie.armor,pvlary caWa,dvect pmb,vmJ
construction to the following:
Divkba of Water Reoarces,Uadergrous l lojeetion Control Program,
FOR WATER SUPPLY WELLS ONLY: f 1636 Mail Service Cash,Raheigh,NC 276"-1676
13a.Yield(gpm)�_ Method of test 24L For Water Supply A fuleetioo Wells In addition to sending the form to
ffV/�V the address(es) above, also submit one copy of this form within 30 days of
13b.Disial"tion type: Amount _ completion of well crostiuction to the county health depentmmt of the county
where CD111m cted.
Farm GW-1 North Cmkoa Department ofEavimom®W Quality.Divia{m of Watr Rcaomen Earned 2-22.2016