GW1-2021-07541_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD L( -1) For Internal Use Only:
J.Well Contractor Information: —_•�
David L. Hardy, Jr. 14.WATiSRZONBS
WellContmctorName mom I TO D)iSCB>pi10N
2906-A R
NC WellConnector Certification Number / fG eh
I&OUTER G for mn1 retard webs OR'LR413R
Aqua Drill, Inc. mom DIA6WM . MONO ,
Company Naome
*� ft ie. 2I
e, 16 DOM CASING ORTLMMG thermal dosed-loo
2.Well Construction Permit#: ^u�y /�� "�l mom TO
4W all applicable nill conmue#on permiu(Le UlC.Comrry,'Stat,,Varfaaee ere) ft R hr.
3.Well Use(check well use): ft. % in.
Water Supply Well: 17.SCREEN
FROM 70 DLANEM SLaram ffiCI�IFBS tVfATFdtW,
Agricultural 13MunicipallPublic 0 ft & ur
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft la.
IndustriallCommexcial Residential Water Supply(shared) 11.GROUT
Iai tion FROM To
mmtmrw soutztmtomar
Non-Water Supply Well: ft
Manitoring1tecovay ftInjection Well:
R
Agwfer Reduupi ElGrouadwater Remediatian -
Aquifer Stomp and Recovery [3SalinityBarrier 19. ! PACK M TOanalleab
Aquife rTist Stonnwater esamvrrdEraoD
Dminege
Experimental Technology DSubsidenc a Control ft ft
C•reothetmel(Closed Loop) Tracer 20.DRUAMG LOG attach additonal slteeb if
Geothermal(Heating/Cooling Rednm) nother(e elain nader#21 Remarks mom oil W- soi!►mar
4.Date Well(a)Completed& 1 � Well� 2,ft u '
So.Well Location: ft tt d'
ft ft
FacOity/OmnxName Facility ID0(ffapplicable) R &
ft ft 21
P ; Address, wd Zip �1 ft tt,
21.REMARNz ,gn ProMb
It
Coemty ParceirdeafifiradonNo.(PIN) n ' WR Sec 10
TI
5b.Latitude and longitude in degrudminutes/seconds or decimal dew
(ifwell field,one lat/long' sum e^ieat) 22. do
!J N
6 U(are)the weil(s)OPMnauemt or OTemporary Si Poore ofCadfi�`Well .
7.Is this a repair to an adstin well: BY sigaing thisJomti!hereby certify t/mr the wdl(r)was( oonrtrrrarad ra oaaavdoireae d
g OYes or Aso wLh 15A NCACWC.0/00 or ISA NCACO2C.0100 WdI Consdrrerloa&zm&rdr add that a
/fthutsar+eparr,�ii!lour,hraerawelt+ronsrrruttonlafosnatloaaadcplotnrherraaarafthe �pyaJ,v+�s+eraotdhasbeeapter+idedtodaetire/laxmer. ' - ,;,,,; ,
' repffirrmd-921 MmOrbseWimoron Ike baatofthisform
23.5i"agram or additional well details: v ?<
&For Geoprobe/DPT or Ciosal--Loop Geothermal Wells having the same You May use the back of this page to provide additional well site demos or well
construction,only 1 GW-1 is needed hrdicate TOTAL NUMBER of wells corrstructieni details. You may also attach additional pages if ne exsseuy
. armed: � 6
�USMITTAL L1VSfRUCTION3
9 Total well depth below land surfacr.
FarmalHplewellsl �alldeptheifdl�erent(enrmrple•3(?a200'amd2QaIQ0'j ( ) fie' Subs*this firm► wMin 30 days of completion of well
Construction to thefollowing:
10.Static water level-below top of casing:_ �� (ft) Division of Water Reso
' .Ifwarerlewells above oasbr&rite"+" uTCes,Information ProtxsslOg Unit,.
1617 Mao Service Center,Raleigh,NC 27699-1617 ,c
11.Borehole diameter. (w. 24L For Iniection Wells: In addition to se ad, the fwm to the m-24s,
12.Well eonsh action method:._ above,also submit one copy of this foam within 30 days of comp! 'on of well
0 -M4W.mtary,cable,diredpasb,etc) construction to the following.
FOR WATER SUPPLY WELJA Or y; Division of Water Retsouirces,Underground Injection Control Program,
,� 16M Mail Service Center,Raleigh,NC 2769916M
13a.Yield(gpm) Method of teak / 24c.For Water Smnuh &Lniectiori Wells In addition to sextdirtg the font to
the es) above, also submit olte copy of this',form Within 30 days of
I3L Disinfection type; Amount: exrmpletion of wean canstrudion;to the county healtli depaitmeat of the county
where constructed.
Form OW-1 Nertth Camlim D epmt=ntof&vuoamcnWQm tity-DivWonofWatuResomees fteviW2-22 2010
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