GW1--00707_Well Construction - GW1_20240125

.WELL.CONSTRUCTION 181E O f(G�iV-1 prin Fotin
Z For Internal Use Only:
I.Well Contractor Information: !
am/
• David L. Hardy, Jr.
14:WATER ZONES • . ..
WellContiactorName FROM TO • nFSCRIlRTON
2906-A 2)mR J3d ' +a ' Vili cep—,
NC WO Coatram orCertifcationNumb& ft f. j.
Aqua Drill, Inc. • Is.Or13TEitCASIN�Gj(ro: .D MER • R>THICRRESS rMT ..
•
Compa4YName f 3'� ft. 6- in �ii.� � JiG
2.Well CoeesR ucgoa Permit Or �J (• ' C` ib' RCASING'OR TUBING( t idosed-loos)
FROM TO DIA BEEn 1hlcmrms MA•E !USL.List aft applicable wellcbnsh:tellonprrmfu a U!G Count,Stint Ymimrcct etc) ft ft In:
3 Well Use(check well use): ft ft.
Water Supply Weil •17.SCREEN: • • -• .
Agricultural I7ewM TO Timerannm matr9TiM �cr ss MATERLIL
s©McmioipaYPublic 0 R
_Geothermal(Heating/Cooling Supply) DRficential Water-Supply(single)
Industriai/Commercial - i°'
�Resideatial Water Supply(shroud) is GROiPf _
Irrigation morn .TO . MATERML ES � , oD&AMO •
Pion-Water Supply Welb R ',7,9— 14-1t 04/. G)-t 1p •��t
Monitoring Recov
ery Injection Well: ft' CLjr
quifer.Recharge 0GmuadwaterRemedtation R
uifer Storage andRecovary • �15a1inityBturier 19•SANBlGRAALti.PAC Kfirapelitazle) _. . •
FRord ID •MATERML ' EMPLACEMENT=TOD
. AquifarTest DStormwdermainage • R ft. _
Experimental Technology oSnbsidence Control f ft •
•
Geothermal(Closed Loop) E3Tja zarnuauuNGLoGrotes&edditiourl sheets irmetessay)
• Geothermal(HeadlieCoolingRettvn) DOther(explain mtderif21Remiss) PROM ?° mt�ca>PeloN rm:rea�taet'sab14e>g�taaindr�,eeei
•
ea I ( fz r//
4.Date Welke)Completed!/2//6/?3 Wellmi? J'L. 3�{ iecl Sr4A/ar
•
Sa'6'Ieli Location: , -�5t co. �yh fie. ' Sir.//L,
.t !ivev .0'7/Aft-e , ft. ft.
Faeitk Ow, rNetme
FusWdy Mil(applicable) ft. ft ht g .
l u
'f� fid327
PhgeieslAaaeesa,citp,oOazip ft. fti. H JAv 5 2024
["dO • 2Li1EMARKS ,• - _ • i 7�• County PmxlidontifraationNo.(PPIN) IrtrJrrfr% Sc^ t rri :l?i+. i�t+igc •
•
.'...,.
Sb Latitude and longitude in de !minutes/secoadsordedmaldegrees: wrr
(ifivellReid,cnef t/lOagissufficieat)
.31 31 2 ?.347 N 710 reforielter
6.ls �•
Is(are)the
( J ' (P) e;rmonent or arCmporray $i of Certified Well• G
� V
7.la this a repair to on eulsfin we1C � By elgdng thfsjhm thereby—I, , that the na1/�),��) b,aka
ljthtstsa is g �Ye or 6.Y+�� with 1SANCAC 02CAlOOor SAIYCACO2C.0200 Wel1 ConsrmafonS7andankond theta
potr11now almwet1centraeetonleomutlonate1=plainthenanaeofthe caPPYtinrncoe has been provkladtethewellowner-
mole under O2l Yap:Mbrea=Or on the hack ojfhls form.
23.Site diagimnt or additional well deti ils:
S.For Gcoprobe/DPT or Closed.-Loop Geothermal Wells having the forme You may use the bank of this page to provide additional well site.details or well construction,only 1 GW--1 is needed. Indicate TOTAL NUMBER dwells construction details.You may also attach*rational pages ifneex ssary.
drilled:
9Y.111114111TALINSIRUGTIONS l
9:7flamt well depute blow land surface: Co c
Formaktplcutelftlist°IMO:hetfdl„Berenrleeateplc.3a@2Qp'mrd2©lo0l ( ) �'F'°r All Wang
Submit tiers forth Within 30 days of completion of well
cotatruction to the foltofviog: •
•
10.Smtic writer kvelbelOw tip ofeosing:, 440 (f1;) Division Of Water R
limner level Is above easingruo +' Resources Iaforanation Processing Unit..
'��77 1617 Mail Service Centel',Raleigh,NC27699-1627
11.Borehole diameter: _�)
CCnn t �/ 241r.For birdied.WaUst In addition to sending the form to the address in 24ei
IL Well construction method: /7 t✓� r> �.7G,�[ above also submit one copy of this form Within 30 days
(Le- ons cable, nietpuelt,etG)
•
construction of completion of well
•
FOR WATER SUPPLY WELLS ONLY: i Division of Water Rersouniees,Underground Injection Control Program,
1636 Ntiiefl Service Cemte i,Raleigh,NC 27699-1636 •
lb-Yield(gpm) • 1/1( (,lpn t Method of t i-j1 A 24e.For Water Swlpty-.d InkeHoa Wells: In edddion to sending the tam:to
13b.Disinfection fyrpe: 7� �/Tff Amemne Me a dress(e s)above, also submit onO copy of this form within 30 days of •
completion of well consttuetion to the County health department of the county
where constructed.
FormOW.t North Carolina Itcyattmeat of Emituniiteutal(balky-Divilion of Water Resources
Revised2.?2-2UI6