GW1-2021-07533_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD (GW-1) For hilemal Ise01113r
1.Well Contractor Information:
David L. Hardy, Jr. 14.WATERZONES
Well Contractor Name FROM TO DESCNIPTM
2906-A 2 "' �/a
NC Well Contractor Certification Number T
✓� 0 ✓ Z
I&OUTER CASING for mula-lased wells OR LINER ,f a
Aqua Drill, Inc. FROM TO DiAhtETER TffiQQiESS MA
Company Name O fr•
I Watermid dosed-Ion
2.Well Construction Permit FROM TO DLOVETM '1ljt:tQNM MATERUL
List all applicable well construction permits(Le.UIC,County,Stale,Variance,etc) R ft is
3.Well Use(check well use): ft ft fa
Water Supply Well: 17.SCREEN
FROM TO DiAMErElt S1.0'r S1TEE TMCIfN)n MATERiAL
Agricultural QMunicipaUPublic U ft, R in.
Geothermal(Heating/Cooling Supply) aResidential Water Supply(single)
ft. fL in.
Industrial(Commercial DResidential Water Supply(shared) Ia,GROUT
Irrigation FROM I TO tI A METHOD AMOt1NT
Noo Water Supply Well: ft
Monitoring Recovery g• &
Injection Well: _
A uifer Recharge ft. D
q � Groundwater Remtxliation _
Aquifer Storage and Recovery 19.SANDIGRAVEL PACK dal Cable
4 ge ry [)Salinity FROM TOMATFiiL►L IItPLAC£bID�rrME1'HOD
Aquifer Test [3StormwaterDrainage ft. TO
Experimental Technology Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20.DRII.LDYG LOG attach atld�t[mnl shme�if
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROM To DESCIUFrMedv et<
4 Date Wells)Compieted•Y C) Well ID# P R
Sa.Well Location: Z " I
ft
.-tIO.��r% `/n/1 S sit<fi d/L ft
Faetlity/OwnerName FeelityM#(ifapplicalle) / & R-
'3 ) .'11 J/C Lam,,, A Nri�� G ; ft. ft
Physical Atty,and Zip ���� ft R up 3
21.REMARKS
County Parcel identification No.(PIN) infnar. Pion Process
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
017well field,one Wong is sufficient)
22 ' cal-
p vy
7L 2-icy . 2-
6.Is(are)the well(s)OPermanent or OTemporary Sigttattae ofCertified Will C eto Data
By signing this form,I he certify that the rr JIN was(sere)constructed in accordance
7.Is this a repair to an existing well: ©Yes or,gNo with'SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill out known well construction information and erplam the nature ofthe ropy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
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 l GW 1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
/Q _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �'/ (ft) 2qa For Al! Wells Submit this font within 30
For multiple wells ltrr all depths tldi ferent(example-3@a 200'mull@1001 days of completion of well
/ construction to the following
Ifwaterlevel is aborre casing,
sac
f Static water[t below top of casing: (ft) Division of Water Resources,Information Processing Unit,
casing "+" J/ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter 24L For Igiection Wells: In addition to sending the form to the address in 24a
12.Well construction method:— /; d C</� �• above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) construction to the following.
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) Method of test �� 24e.For Water Supply&Injection 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.--- &A Z. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Envircamental Quality-Division of Water Resources Revised 2-22-2016