HomeMy WebLinkAboutGW1-2021-00361_Well Construction - GW1_20210127 Print Fot7n-. ::
WELL CONSTRUCTION RECORD(GW-11 For Internet Use Only:
1.Well Contractor Information:
David L. Hardy, Jr. zolas,
Well Conaactor_Narae mom TO
2906 A R
,�
NC Well COntriaor certification Number
1S..0tr=CASING Pof mnitieated welbloll.IdNBR a
Aqua brill, Inc. FROM I To D
ft.
Company Name !/
�� fti INNE1t CASING"OR TUBING dmtd•too" ,:';
2.Well Construction Permit gk[J /0✓r.2 FROM TO I I T ��w,
Lint o!1 applicable veil construction permld(Le(IIC.Cormry.Stag Yoriance,etc) Ift
ft: 60.
3.Well Use(check well use): ft. Iia.
Water Supply Well:
1Ti SCREW
M TO DULMEIFB sm sm I Tffi MATM41
Agricultural [ MunicipaUPublic Q & ft in.
Geothermal(HeatfiWCooling Supply) MResidendal Water Supply(single) ft, R
IndustrMCommercial Residential Water Supply(shared)
18.GROUT
hri on FROM
ao
AMo
Non-Water Supply Welt: tL
Monitoring Recoveryy R tt
on well:
Recharge [30roundwater Remedistiotl
uifer Storage and RecoverySalinity Barrier 19.SAND/GRA. PACK der eabk
FROM TO WATENAL-, Pscro D
Aquifer Test OStormwater Drainage ft. ft
ExperimmW Technology [3&"dence Control ft.
Geodumnal(Closed LAMP) DTMM 20.'DP.KJMG LOG attach addiRonai stroefe if '
Geothermal(Heatin ool' Rtatnn) nOther lain under#21 Remarks) EOM sotvsoac
ft, h9 0. �f
4.Date Wep(s)Completed: Weil tuft • iL r.
$a.wen Location 211. l �
Fa%W0w.=Name Fac,Yity IDO(ifaPPiiceble) 8
A .City,ark zip h�OJyJ ft. it' ;
RBMAPM
Co�t3 Parcel identification No.MN)
fib.Latitude and tongltade in degrees/minates/seeouds or decimal degrees:
(ifwetl I .
oe'.IUNlong is sutHcient)
22. no
9 N. al/ 7S�'6 w �
6.Is(are)the weil(s Permanent .. or OTemporary ,' Si ofC ' ed well Canhaa�
nkn__ gnittg thisA-I hereby crrtlJy rhar.the,trrJl(s)1ir i(wens)Constructed in aoaerbnee
_7.Is this a repair to an exisfing well: Dyes or�to 2 15A NCAC 02C.0100 or 13it NCAC 0?C:0200 well ConrtnWilau S and rant a
1 this it a re
1 palr,'yrlt outAnawn weft Coutstruetlonit�brma!!on erptoJn the --dte roPYofdris rrcwtd hasbeenprovhfed to the well owner.
repalrunder g21 remarkssedton oron the back ofthisform
23.Site diagram or additional well detat7r �� y
8.For Geoprobe/DPT or Qosed-Loop Geothermal Welk liavM the same° You may ties the back'of this page to plrovide.gd 66nal,ail srte it s nit well
aaasbUction,only 1 OW-1 is needed. Indicate TOTAL NUMBER ofwells construction ddails You may:also aft ddth iat pages if n
drilled , , .
/}_ SUBr„11TALIlV$37RUCTIAiVS
9.Total well depth below land surface:_ •' // (�) 24a.For-
A- erent(aoompie-9(o)2p0•and2®100�"' row [Ali �thisfomr �+ithm 30 days-p completion of well
n�f`
10.Static water level below to of
Iftvmer level i4 above eras ,p -- ��'� 00 Division of waterrReton Information Processing unit,.
use +� 1617 Mail Service Centet,Raleigh,NC 276"-1617
ll.Borehole diameter. (in. 246.For Iniectfon Wells: io drtion' �etrdmg;the form to the address in 24
12.Well oanstraetion metfrod: above,also submit one.copy of tWs foi4i wrthm 30 days of completion of well
(i a anger,mmsy,cable.dinxt pnah ate) exmsttuction to the fallowing
FOR WATER SUPPLY WELLS ONLY: Division of water Resoai ees,Uadetgronpd Injection Control Program,
I636 Mari Service Center,Raleigh;NC 276991636,''
13a.Yleld(gpm) Method of test: �/ 24L For Water Snnnly' eieefton W s: In,addition to sending the form to
the address(es)�abova,:i so submit-one copy of this,fotm within 30 days of
13b.Disinfection type: Amount:JAPA completion of well consttug0gn m thecounty hearth departmmt of the-county
where com ttmted.'r" z
Form GW-1 ! ;�. ¢ •.:
North Carotins Deparhneat of eavuualoo al Qmiity.Divur�of Water itoomees ti �'Revraeii 2 22.2016
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