GW1-2021-07532_Well Construction - GW1_20210903

Print WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Form
1.Well Contractor Information:
David L. Hardy, Jr. 14.WATER ZONES
Well Contractor Name FROM TO D
2906-A F l-4
NC Well Contractor Certification Number F16tal
1 R C SING for multitaseti welle OR LINER if a lin
Aqua Drill, Inc. �aOM To D Tffi I St IA
Co mpaay Name % ft irti i� /
16.INNER CASING OR TUBING theraul closed4000l
2.Well Construction Permit#: FROM TO DIAMETER I nUCKKM MATFJUAL
List all applicable irell construction permits(i.e.UIC.County,State,variance,etc) fL fL
3.Well Use(check well use): N• & is
Water Supply Well; M SCREEN
FROM TO DIANW= SLOT SM TMCKNESS I MATERUL
Agricultural QMunicipaUPublic U fL tt. In,
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) % fLin --
Industrial/Commersiai Residential Water Supply(shared) Ig GROUT Irrigation FROM TO METHOD&AMOUNT
Non-Water Supply Well- G7 fL
Monitoring DRecovery & R
Injection Well: —
Aquifer Recharge QGroundwa tL fLter Remediation _
19.SANDIGRAVEL PACK(ifaisplicable
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL — 11301ACEMENT n>EMOD
Aquifer Test OStormwater Drainage & &
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOU attach additional sleets jf
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DEKRWrM— dm etc.
Li_ - n I & G1
4.Date Well(s)Completed: f _ Well ID# R Z IL
Sa IVeli Location: fb O
CIS
Z 1'R �t • l
Faariliry/Owner Name Facility!D0(if applicable) h
6rle"i /tlL'r7•� ����(�C3 1t 8
Plgsiaal Aftesb City.and Zip ft. fL
21.
CoMtyV Parcel Identification No.(PIN) ftffO�rnmssing Un
ft
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DWR SQCt1On
(ifwell field,one lallong is sufficient) 2 e
6.h(are)the wells)joPermanent or Temporary Signature Certified Well on are
By signing this form,1 hereby shot the wells)mt(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or.MNo with 15A NCAC 02C.0100 or 15A NCAC OW.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction J formation and explain the nature of the ropy of this record has been provided to the well owner.
repair under 921 remarks section or on the bock of this form
23.Site diagram or additional well deicslis:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
�I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z ('For multipleA) 24s. For All Wells: Submit this fora within 30 days of completion of well
wells llrr all depths ifdi�erent(example-3�a1200'and 2@100') construction to the following:
10.Static water level below top of casing: 00 Division of Water Resources~information Processing Unit,
lfwater level is above caring,use"+" og
1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. (ia) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /� above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) — ' construction to the following.
FOR WATER SUPPLY WELLS(MY: Division of Water Resources,Underground Injection Control Program,
< 1636 Mail Service Center,Raleigh,NC 276"4636
13a.Yield(gpm) Method of test: J t 24c.For Water SuoDiv&lujectioa Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Cam` completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Dcparvncut of Envirormental Quality-Division of Water Resources Revised 2-22-2016