GW1-2021-03526_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD fGW-1_l For hmnai Use only: dd
1.Well Contractor Information:
David L Harder, Jr. t4.WAT=ZONBS x
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Wall Conneet"Name
2906 A ft
NC Well ContractorCa dfiaatianN=*= MD RCA�D fo mw � OR UM madam
Aqua DOI, Inc. mom ZG
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Company flame ¢
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2.Will Coustrnctioa Perutit#. �11 � To n �' '
LW all applicable hell constrnetfen permfu(te.U1C.Cam%State,Yarfanes.wJ & &fL
itl'
3.Well Use(check well use): ia.
Water Supply Well: t7.SCRB)�T
m 1TO
Agricultural 13Munia paUPublic 0 it, fw fa.
PGeothemtai(HeethWCooling Supply) GResidendal Water Supply tie) . tt. ft. in.
IndusWW1Commet W OResideatial water supply(shared) IL UT .
hri en
Non-Water Supply Well: Ott r ! c
Monito' R R
on .
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Recharge �t;rotmdaRamediation
Stomp and Recovery Osalinity Banner 1IRM 9.SAIVD/GRT PA i+ill fif t .
AQuifer Test OStormwaW Drainage ft.
' Experimental Technology. OSubsidmoe Coatl ft• j
GW temaal(ClosedLoop) OTincer -2LDRVJMGIM atteeb&WdW 1 ff
FROMt3eothemtel eati ool ltetnm Odtm( lain uaft#21 Remarks iZ $
4.Date Well(s)Completed:j 1� 4�`� Wen WO R' f'-' I
Sa.Well Laeationt � � � ! ,
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F�awlety NamaN�ta FaerlitylDOC +PFliaabta) m ��
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_ >G 4- 1 AIN
PomlIdeniGationNo.{PlfTy ri'. t'sOl1 Prc^esstR
5L Latitude and kougltude In degreedtalnuteAcconds or decimal degrees:
Gt field,one 1eUlamg is aafilafeat) cats
6 Is(are)the weit(s}jUPermaueut or �emparary wofiftecan"Wacwhew Date
7.Is this a re By s�Nng thbt fmm,I hereby cc*that the wWfs)was t�1 aarrt aaW br a--bnee
pair to an existing well: DYes or Jio wt►h iSA jWAC ox.OIZV or 15A ACAC 02C.02M Well Con o-Who lr and dbat a
Ifd&fs a mpa[P.P11 ombrmm wo f omadudfm f1*=t1onaad arptafn*Ono&"ofthe cWcf&ls teawrdhas been provided to ft wetl owner
repair under eel remarAssecllar or on the heal afthlsjbrns 23.Site diagram or additional well deta0st
&For GeoprobetDPT or Ckased-LoopC*thermd Wells having the same You may use the baelr of this p$gs to ovtde additioaai wall site detm7s well
eonsttuction,only 1 OW-1 is needed. Most*TO`1'AL NEBOOt ofvtefis construction details.L You may also attach additional pagan if tom'.
drilled:
� "�AI��'I�tICTIONS
9 Total well depth below had smtaee: 19 24&For Alt W - Submit this form within 30 days of compledon of well
Farmattt�e wdisltstattdcFing let('errnttmrompto.3(rr1200•laad2(aJ100ry constm dion tothe following:
10 Stacie water level-below top of easing: l,"o J _.._.(ft) Dtvlsian of Water Resanrcea;Infornatton Processing us%.
lfwamrlad is abov Calft use f" 1617 Mail Service Centers Rddgth NC 276991617
11.BoreM►le diameter: /NO 24b.for In( A V1reDsr In addition to sending the form to the addmss in 24a
s also submit one copy of this flum within 30 days Of txuaplation of well
IL Well construction method: ,r emtstnrctiorr oo the fogowiag 1
{ie.anger,rotary able.diteetpua6,etei ,
Division of Water Resouices,Undeirground Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 16M M H Service Centee,Raieigb,NC 276991616
13L Yield(Rpm) I Method of test: . A 24c.For Water Smasfi&Inieetion Welke In addition to sending the foma to
y j/ #tu address(es)above, also,submit one copy of this fomt vvititk 30 days of
13b Disinfeetion type: ! f/ Amonob G completion of wall construaian to the�ounty health department of the county
where camstrttcted. � i
Form OW-1 RaviWN222016