GW1-2021-01149_Well Construction - GW1_20210215

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-WELL CONSTRUCTION RECORD iGW-1l For Interned use oniy:
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1.Well Contractor Information:
David L. Hardy, Jr. la-WAIM ZONNTo DESCRVTM
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WenConuacwNamc ixoat
ft
2906--A fry &
NC Well Contractor Certification Number OgR CASING >seDs Og
Aqua Drill, Inc. mom � D �r
tL f� 1m
Cony Nsme «. 16.INNER CAMG OR TUBING
2.Well Construction Permit#: _3 61A ,14 TOLWatt applicable erell eomnctfos permfu(bn-WC Carmry,&ak,Variance eta) it &
3.Well Use(check well use): R `
Water Supphr Well: TO 17.SCRESfit OUMEa�tt am > +
AgriculturalI++iunicipaUPublic 0 in.
Geo1h=al(HeatmWCoo1mg Supply) MRMdcuW Water Supply(sawn ft. it, fe.
Induswwcommes w [3ltesidentiad-Water Supply(shared): i&
n o
Non.Watw Supply W+dh
Mend nog Recovery !ti ftn W.1
: fL
Recharge 0(hount walaltemediation
uifer Storage and Recovery 13SWir*Barrier FK SANB1(3RTO PACIi AMISMIU. IStye nMsSaHI
AqullbrTest C)StomnweterDminage
& R
Experimental Technology [Subsidence Comrol & ft
Geothermal(Closed Loop) OTracer 20.11)RUJANG LOG(aft baddifieW if `
GaNhermad eatin ooi' Ron.) nOdw LegbTO
in
j ft. R G°
4.Date wows)Compteted: `r a ell M# R' 'G ,- e'
Sa.weil Location: �'' -
Ila
77
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FaeilitgfOwner Faefiityrll?#(Ifapplicablie} 1L ft ,,
llf ft. (to
Physiei'Ad#eeat.Cirl =d Zip 1 � R. R.
, � zi:REMARKS .
County 1*arcelldentific�ionNo.(PIIO
Sb.Latitude and longitude in degi+walminates/aeconds or dechad dam:
Cjfw4fiald.on Wong is suffieieot) ,�, •p
,3 A� 7 N am. d W
6.h(are)the WWSADpermanest or DTempor7iry Sipa&k oft fled Well Cow
Iffy twos arcs farm I&raby that the w Ws)tar(war}omxauoted in aaaordasoe
7.Is this a repair to an emsdag Well: 0Yes or 13NO wlth 15A NCAC 01C.0100 or 16A ACAC 02C.0200 Welt Convuedw Swnftdr and that a
If&&tsa repam fill ostlrta"well aws& o*n 10rAufteadawkfa atnasrte ofthe capyafthts=wd)osbees;pontded to dnw it owrut:
repafrrarder pIl rammkssectfas oran the borhofthfs form
23.Site diagram or additional Well details:
L For Geoprobe/DPT or Closed-Loop+Geoi'rmud Wedls having ft same You may use the back of this page to provide additional well site details or well
construction,only 1 GW I is needed Indicate TOTAL NUMBER ofwells construction details.You may also attach additional pages if necessary.
drilled: S!tBM1TL'At INSTitUCTION,
9.Total well depth below land surface: ? 00-744,Ear Ali—Wells: Submit this form within 30 days of completion of well
Form dtWe wells/W all depths jf&ffemw(e=Wk-3@200'asd.2 ,„,>p ?- to the fold
10.Static Water kvd-below
rfwater level is above use of+" ��� (�) Division of Water Reaoaras,'Information Processing unit,.
E 8 15 2021 1617 Mail Service Cew,Rabb,NC27091617
It.Borehole diameter. ) aConMMnwtDthMetf70H0WW11wiWr
We o In addition to sending�form to the address in 24a
12.Weil oonstraefdon method: py of this fox n within 30 days of completion of well
' �� ,�'0�l
DMslou of Water Resowiees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center",RAdglt,NC 276916M
13a.Yield(gpm) Method of test: A CA 24e.For Watersmak&Injection Wdlx In addition to sending the form to
the address(es)above, also submit one copy of this fwm withal 30 days of
13b.Disinfection type. Amount: e f-F, completion of well construction to*a county health department of the county
where Caftstructed.
Farr ow-1 Nw*Carolina Depubu t ofFnWmm=WQw ty•DMWmn ofWate rRes urm Revised 2 22 2016