GW1-2021-00354_Well Construction - GW1_20210127

1
. P1.1 ' tiff
WELL CONS tUC 10 IREC�t3RD[GW-la For homal use Only:
1,Well Contractor Information:
David L. Hardy, Jr. 14.WATERZONM' -
WaUCoatraetorName FROM TO
NC Well Contractor Certification Number 25..OUTER CASING for iaaifleared. OSLINEIt F
Aqua Drill, Inc. SROM To niwM Mn
ft lam
Company Name Car AYNER CASING OR etesedrt
2.Well Construction Penult#:i_ FaoM TO rsu:ratEss MA7FRiAI.
IA#aft appilcobte wdt eo ftefion wrmttr e.U C.Cbwo Smw,Volaaca,air.) '
3.Wen Use(cbeck well use): IL
Water Snooty Weil: VSCR>'ITO `.tt a�►i rat,
Aoculttual MittticipallPUblic On iw "',;;TM
Geothermal(Heatitrg/Cooling Supply) Residential Water Supply(single) ft, tt *,
IndttstriaUCommcrcial 9ReMdenfial'WhWSupp1y(ftmd) IS,GROUT
Irti on M e
Non-Water Supply Well: , c"
Monitotirtg Recovery a
eeftu wen:
R R
EGwffienhhal
DGtonndwawRemediat an
19.SANDIGRAVEI.P CR hie fer Storage and Recovery 0SalinityBahia FR M To tau+ �rt o>atbr Test OStarmwate�r Drainage ft. ft.rimental TecWtolov 0SubsidenceControl f �hermal(ClosedLoop) E)TMM 2Q°ARILLiDIGJAG attaethaMd tmt if actin ool' Return . Other lain under#21 Remarks) F6QM ro D 6.rdeee.soahaac
® ft. R �
4.Date Wells)Completed: •• Wen LD# ft.
sa well Location.
tt. ft
FaerlitylO Neau Feo tyWO(ifiolicable) R R.
fL
Alj' gh
oa! , i. F ft. ft. y
21 RRMAM
• Pa►eel Idaatificatioallo.(PII+1)
5b.I.atitnde end longitude in degmesfminutesfsecands or decimal degrees:
(ifweU field,ow huJIM is au 22. lion:
Cohift
6.h(am)the wens} Permanent or DTemporary Sigrmtsac of Cenifiod Wellt?ate
7.Is this a re BY stgrrirtg rhts•J6rm,I heroby :�the tettfs}imr:(;arasi s+Dr»,fd�Cttd 6±
pair to an exisfjng wen: OYes or jWo wUh 15A NCAC 02C.0100 or 15A NCitC 0?C'020D il'e1/Cotmrualaa Slrarrdaads attd that o
Ifrhtsts a rrspatr,,Jfllorabtoxm wall eortsar�aion ir�prmatlon at�erptafa rha netwr ofdrc,'.,.? evpyofthisrecordhas beau provhles�t�� ,owner '- .r
repalrnadtr td21 remrtrkssacdon oron rite badkojJhlsfo'rm. +: �. :. =
23.Site diagram or additionatwSdctytBs: e
L For GeoprobelDPT or Qosed-Loop Geothermal Wells having the You may use ft back of tWs'Pao!to`ptovida additional wol!-stte deluge Or Wen
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of 's ��t on des You may also attar t dtbonel gas tf riec ry
drilled; 1 SUB�V117TAL IjVST U IONS
� a
,. 9 Total well depth below land surbew,,_, ✓' 1 (�) 24a For All Weir", Submit 1hr51artm rhnthm 3Q days of coriipletion of wa
ForamtnpkwrttsttuaudeplhrtJd rrrfraaomple-3�to0'mzd2�ADo'Y'" cot buct'tontothefollowilIF t
10.Static water 1"Idow top of casing: (ft.) Dhrision of Water Reaonrecs,Intormationpr,g,I Unit,.
1f kvef is abova auft"W .+ 1/ 16171Vall Service Ccntei,Rakish,NC 276"4617
11.Borebole dlamaten �/+ on.) 24br For Infection Wells In addttron in sending the form to ilia address in 24a
12,Well constriction nnttbod: t' above,also submit one copy of this fki66-v thk 30-days of completion of well"
(i a cheer,mut cable.dita mom:etc) COnStIMd t t0 the f0H0WMX
Divlslon of Water Rmonicee.'Unde ground Itrjiettion.Condot�►rggrasm,
FOR WATER SUPPLY WELLS ONLY: 1636 MailSrvicCsdriss ;NC 27699i63G''
13a Yteid(gpm} C! McWod of test: ^' 6'- ': For Water Sum &Inieclioa'Wens: Ia a tbon to sertdifio the form to
dw address(es)above, also submit ono copy of this f!o t,witWn'30 days of
13b.Dlsinfecdon type: f'' Amount: aempld► ad l`cnnsfntction to thg county health depardnaht of file county
i
Form OW-1 NorthCaroium Dapm pneat'af Eavuo t 4ceUty•Divisiaut of WaterResouroac Reviled 2.22 2016