GW1-2021-03695_Well Construction - GW1_20210823

Pritrt Form
WELL CONSTRUCTION RECORD(GW_1) For Intemal Use Only:
1.Well Contractor Informadon: -�
David L. Harder, Jr. 14:WATERZONSS
Well ContractorName FROM I TO DESCPJPMN
2906 A r
NC Well Contractor Certification Number
X0 ft 77,7 !�
15.OUTERCA G for... ' we$a OR' rf
Aqua Drill, Inc. FROM To DM 7M „�A
Company Name
16.INNER CASING OR TIJB1NG osedaoo
Z.Well Construction Permit#: �z�/>GDD Z(j FROM m Drr►n��ER : 7fficxi0ss MA7saw,
Ltrtall appBcobie"'all consbuction permits(Le.IIIC,County,State Yorimtce•eta) ft R in.
3.Well Use(check well use): R I R in.
Water Supply Well: .17.SCREEN
FROM TO Due surrsmp I ffiCEN s MATERIAL
Agricultural [3Munitapa public 0 it & im
GeOthernnal(Heating/Cooling Supply) Residential WaterSupply(single) ft
IndustriallCommetcial OResidential Water Supply(sbared) 18.GROUT
lwgadon FROM TO ElniFl A AMo
Non-Water Supply Well: % ft R
Monitoring Recovery R ft
Injection well:
Aquifer Recharge 13GroundwatcrRentediatian ffi
uiferStorageandRecovery Mini Barrier 1 SANDiGRAVELPACK rfa k
tY FROM TO MATERIAL ZMACEMENMEIHOD
Aquifer Test E3Stormua r Drainage S ft
Experimental Technology DSubsidence Control ft
Geothermal(Closed Loop) DTMM X DPJUMG LOG attach additional sItats if
Geothermal(FIeating/Cowingmgm) noota(explain under#21 Remarks) FROM 7+0 DasCTtmlmN or hardaee.am7hodc atasdc
^ '1 fb ft r
4.Date Well(s)Completed: well M# R ft
q
5%Well Location:
FaediwowmNama FaeflityIDtf(ffapplieablej ft
Zak l ,max!gdyD d AL 27 7- %
Physroai Address.City, d Zip �_7 ft. ft �r 1�Cs•
Aie1/J �j'J 21.REMARKS 3�
C
orb' Parcel Identification No.(PIN)
5b.Latitude and longitude in degradminutes/seeonds or decimal degrees:
GfWell fiat
d' 2
2 C 60M r /�
6i
6.b(ore)the well(s)OPermoneat or OTempotary Si e ofCatitied well Contractor i Dan
By Oping this form,I herby certify that die wdl(s)vas(ace)rawtttraeted►a oceordanee
7.Is this a repair to an existing wen: OYes or F)No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Wdi Conumu on Standards and that a
Ifthis is a repaJ-fll out An—well eomtmpion Information dnd explain thenoonr ofthe copyofthts record hwbew pmvided to the well owner:
repatrunder 921 mmarkrsedion or on the back ofthtrfomL
23.Site diagram or additional well d_etaft
&For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page M provide additional well site details or well.
construction,only I OW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pikes if necessary-
drill
�� SUBMMAL I,)MMUCPION3
9 Total well depth below land surface: _( ) Ma.For All Webs Submit this form within
30
For-dilple wells ltrralldeptbj fdlfferenr(emmple-3(a�200'on 2@lo9j days 6f completion'of Well
construction to thefollowing t;
10.Static water tevel•below top of casing: (ft) Division of Water Rego
Ijwoterlevel is obatir a¢slrr&rcu'•+^ ureek Informa)ion PCocetiiw Unit,. ,-
1617 Mao Service Center,Ralagb,NC 27&"-1617 '
11.Borehole diameter, In.) UL For Injection Wells: In addition to sending the f i n'to the address in 24s-
12.Well construction metboil: _ /f�u�y above,also submit one copy of this form within 30 days of completion of well
(ie.auw;rotary,cable,ditectpsb,am) ' cxnutruetion to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,IIndergronnd Injection L`ontra!'-Program,
1636 Alan Service Center,Raleigh,NC 2719=1 "
13a Yield(gpm) Method of test: S� 24c.For Water Soanly& iection Welty: '• * sC a! In addition to form to
/I / the addrew(es)above, also submit one copy of this forrt(`within 30 s of
13b:Disinfection type: i7 Amounti b completion of well construction to the county health depwituliatsot` couiny =
where constructed.
Norrb Carolina Depmomomt of Emmai Qmality-Division of Wider Resomcea
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