GW1-2021-02250_Well Construction - GW1_20210722

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WELL CONSTRUCTION�REC{?RD(GW--1) For Internal use Onir
1.well Contractor Information: :h
David L. Hardy, Jr. :14..wA Rzoms TO D-
well ConrraetarName FitoM
2906-A m
&
NC WON Contractor Catification Nwnhax MOUTER CASING(fibi moltleued OR-Ll1 M
Aqua Drill, Inc. FROM % DIAMEIER, 2 BUTERML
C°m°°°y"°°" �) ITT
lfa OR lrtxsR TUl32N
2.Well Construction Permit# oM T4 DUMa'ras' I 7R03MM I MATERZOIL
tdnatt oppltoable hell comVuellon perm u(Ge IRC,Coermy.Stag Vw1anet.eta) ft, x in. a
3.Well Use(check well use):
.17.SCREEN
We
terSuppiy Well:
M TO D lSLO? lttt lliA
AgriculltualluitmicipaUlrtrbiic 0 ft. ft
Geothermal(Hating/Cooling Su)giy) 121tende dial Water Supply tamgmi ' tl, #. 'a-
Ind ustriaUCommemia! ResidtntialVater Supply(shared) 1S -
Irdation FnOM TO @AMO
Non-Water Supply Weil: ft.
1,00- 4Wt
Monitoring Recovery R R
'M W l:> ft. tR
Aquifer Recharge DGmundwater Remediation
uifer Storage and Recovery QSalinity Barrier 19.
SAIVUVGRAVEL PA 6la. 1nr3oD
Aquifbr Test oStOrmwater Drainage R IL 1
Experimental Technology OSubsidemx Comml
iGeo*mrraw(Closed Loop) DTMM X DRffJMG LAG atbah Howl iP
FROK TO a6�V sawfacktMadu=1
Geoftnuai earl 00109 Retum Odra( lain muter#21 Remarks
4.Date Well(s)Completed/__:L/__�L Well WO ft
D'
5 well 1A Mtiou: Ile &
Fan' weer "S/� iisa{efeyplicabk) / & 1 �.
A( �a ft ftUl
�� z1.RsntARtcs
Conroy ParaUdenbficubusNo.(PIN)
Sb.Latitude and longitude in degreestminutestsecouds or decimal degrees: t rtuli" `�r•cj6�r Cn tc
(ifwdl field,on Iat/long is mfficiia n) 22.,Cerdfiearl
N ! 2. r
6 1s(are)the weil(sar"Muent or O emporary Sigmnsca of as:ifrat Well Data /
SY sWP4 dds jbrm,I hereby coo tear the wvllfs)rap Oxen}cwu&med In aomrdm ee
7 L this a repair to an existing Well: E)Yes -or Mho . _with 15A NCAC 02C.0100 or 1SA NCAC 02C.02M Wdl Con~rmr S9andw&and that a
Ifzw tsa mpair,jW out&MMWeWnwUttmr tlta name ofthe owof&&rewrd has been provided to AV"a OW)et: 1
repatranrler d21 mmarkasedton or on the backofftform.
23.Site diagmin or additional well debrits:
L For GeoprobehDPT or Closed-LOop Geothermal Wells having the servo You may use the back of this page to provide additional wep;stte details cr well
construction,only l OW-1 is needed: Indicate TOTAL NUMBER of wells aonstructton details. You may also attach additional pages rf n r.
drilled
f SUCTIONS
9.Total well depth below land surface: 242.Far All Welisr Submit this fomt anthin 30ydays of c0mpiatroA`af well t
Pormcdtl�awrl/s{6taitdepshrtldjjJ"eretttOaroml+le-3Q2LDQ"andl(a)100ry congh„cgonto the foU following:,, �, r
IO.Static water level below topof ca `?"ft. Oil:) Division of Water Resources,Ii)fo ateon 1pr U-.0 ,.
OJ warerlevd IS atwve cmtrtg use 1619 Mao Service Ce2 ,�NC 2Tb94�'6� 1 r
11.Borehole diameter: 24b,For ini n Wells: In addition toseadmg+ ie`f0fm t0 the address in 24a
above,also submit am cagy of this form wrtltiri 30' ,,Of
completion of well
12.Well conattuMlon method: COtrilCtiOn to the following
(i.e.angler,rotary,oab1R dit¢et push,eta.) <-:`
Division of Water Resoni eear Und2rgronud{ nControl Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,'R*1914)VC0699 I63&
I3a.Yield(gpm) 10
Method of test: �� 24� Inarditi 'to sends,the form:to
/� the address(es)above, also submit ono' of tiurs�'wrthin 30L"&ys of
13b.Disinfection type: r Amount: completion of well construction to the county heahh dep'aitrnapt-of.the'county
where conAructed.
Form OW-1 Norlh Co oliea Dapra bnW ofFAvirc mental Qudky-DivWco of Water Raso>ases _f Ra±rued 2- L'_2016
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