GW1-2021-02318_Well Construction - GW1_20210722

Pfirit Form.
WELI.coNSTRyQT O RE ,Oa[iD�Gw:i) For 3ntematUse y:
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1.well Contractor Information:
David L. Hardy, Jr. 14.ATMZONPS
We11Coaus"Nema ,.� M 7t
2906�-A R L� f
NC Well Conmmr Cenifiaation Number WM,0U:=RCAMG(fWm pB'LiN&RAqua Drill, Inc. q ,cam eam>NmyName ,CT it.C�A -�-cx>S2.WellConstructionPermit#: ' hL
LbtdiWileable iretl cmanrnetlan pmnlu(Le U1C.CoUWA State,Vwfaace,do fL
3.well Use(check well use): R
Water Supply Well: .17.SCREEN
m �+u sot sta
Agrieulttuat �MtmicipaUPublic O ft. &
GecOMMOI(fleabWCooling StQ*) DRestdetkel Water Supply(fie) ft. fo ia.
Indtsatrial/Cammeccia! �Residetntial water Supply(shared) ILGPAM
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Non-water Supply Well: ,•
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19.SANDlGRA. PA re
Qaiter Storage and Recovery 13se tty Barrier = MATEMA.
AQniferTest OStonawaterDt hop fs fa
Experimental Tedmology DSubsideaoe Cornrol ft; R
Gw*mmd(Closed Loop) DTraCer 20.DRu1.1N 1AG attachTO
addi6otal if
Geoibetmal east col Reton 110ther(oxlain under#21 Remadai
4.Date well(a)Completed.6� ` WeU @if IT R' R' r
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CCUV4V* Pmsel IdentifiaetionNo.{PIN)
Sla Latitude and bngttnde fn degr mia>mslsecondsordedmal degrees:
Cafwall,field.o ongisao8iaientj C/��/� L C to
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6.Is(we)the welt(sj F ne or DTemporaty Si&Yft Me OfCatified WVONBy+'o t8 Ws -^I hemp='0'0�w*v1w#jrk)*ow trar1 cm&netet fn ac mdove
7 Is this a repair to an existing well: DYes or PNo W*15A NCAC 02C.0100 or 1SA A7.AC 02C.0200 Wdl Comtnxdm Siw dm:tsand that a
Ifthisuanrpalr ftllMtbMmVdleorat>=*ff 14%wWonand erphib the numn of*e eopyafthtr rand hasbaen ptavtded to thewell oatnar
repairaaader#21 renrarlsseeftn aron the back ofthtfo 23.Site diagram or additional well details:
L For GeoprobeMPT or Closed-L"p,C,cotba"d weft hff ft dM Moe You may use the tact of this paws to ptcvide additional well sits deta7s or well
construction,only 1 OW-1 is needed Indicate TOTAL NUMBER ofwells consuucdon details. You may also,attach additional pagca if ucco n.
drilled' _ SUBMITTAL IIVSIRUGTIOIVS
9.Total well depth bdow'fagd surface A,,� ?Aa.For AU, Submit this fo.m within 30 60 of completion of well
Forinddple veft A tagdapths#j era7tt(enaaarpla- r OA'aad T�100'i consinudion W the following
10.Static water kwel•below top of easing: (fL) Division of water Resource.Igibrn adton Proms Unit,.
Vraararkud is above amtag we u+/^ 1617 Mail Service Center,Raleigh,NC 276"-1617
It.Borehole diameter. b ( ) 24L l¢ In addition to sending due form to.the address in 24a
IL well Construed"method: above;also submit once copy of this faim within 30 days of bbuspi t of well
oodon tothe following: ((
{i.e.augatia�y,albio,dinxtpush.ao.} �
Division of Water Resouiees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: r 1636 Mail Samoa Center,Raleigh,NC 276991636
LU Yled(gpm) - Method of tech sJ} 1 24c. M
I Lt`addition to sending the form to
the addresses)above, also submit one copy of finis fmm within 30 days of
13b.Dielnf don lypo Amount: completion of well construction to the county health depamnent of the county
whet constructed.
Form13W-1 Nw&Camli=DcpnbnWofEavhumenmiQu ty-DwWanofWswiimounm tterh dZmU2016