GW1-2021-00250_Well Construction - GW1_20210125

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Wee Contractor Information:
David L. Hardy, Jr. 14.WATER ZONES
Walt.ommtorName FROM I TO I DESOaIFnON
290E A
ft. R
NC Well Contractor Ce,ti6ation Number
IS.OUTER CASING for ead web ORI.RVBR
Aqua Drill, Inc. FROM 7n oLiNLI TW('HImaB w
Coayfny Naar / R• i Y/FbL l Z f
(7 L7l It INNER TURMI
2.Well Construction Permit lF: � > FROM DLtaR7LR MA7alW.
Lul all appllable veil anravction permiu(Le UIC,Lc.6,y Smrc,V'L�) R R ice.
3.Well Use(check well use): R R. le.
Water Supply Well: 17.SCREEN
Pam 7'O af.01' mATiBdL
Agricultural QMunicipaypubhc 0 R R. R.
Geolbermd(Heating/Cooling Supply) Pesidemial Wets Supply(single) N. ft. ft.
IndustrieVCommemial Residential Water Supply(shared) IS.GROUT
Irrization To Tafat. o
Nonwater Supply Well: FR L+R
Monitoring Recur, R ft.
aY
R R
LGwOmmal
Rec6erge CJOramdunow Remediadm .EAND/GRAYEL PACK dStorage aural Rarovery - ©Salnity Boma vaom To isn4AC13UWP1nirftonTen ❑Stormweoer Domaga R R.
mtd Tec nology QSubsidence Control R - R.mal(closes Loop) QTracer 20.DRRJMG IAG aaati sal dmd ff(Heating/Cooling Rehm) 130ther lam under a21 Rematka veom To
R
4.Date WcU(s)Completed: / z I Well ma R• -
Sa/�3/YeO
F�J—LY Ngmj/--j /
Foal' mrNana Fm,Lry me(ifapplinble)
ZC 17 171 _ i at ft.G l G : t ><rr
Phydal Address.Ci . �1/� L 7l 2- It. R
Y 21.REMARKS
Cody Rural ldeetifiaboo No.(PM)
5 weu field.one
d and longitude in de`reealm as lmooWsecon or decimal degrees:
O°s is suHia or) 22>.&IMice
6.h(are)the well(s)CgPermaneot or J:j7'emporery Sipmare ofCem w Wen C =
ng By-�rw OPS)b sr,,I he,eby cessS/1'rAw Ar wall()noraroe(wen)caebd in mmrdonee
7,la this a repair to ao nioli well, OYes or [DPio w14,ISA ACAC 02C.0100 or IM ACIC 02C.02M Wd1 Comnardon Sevndrdr addmra
11OLL.eanpmr fill ow Mown well eaerembn lgformmlon Indoplab she soave of 1, spy oJOW ra pro nrdhas beenvNdm si
ll ill ones.
mpmrsdv 421 resortraeeaw,war do bad tldbhng
23.Site diagram or aduRtbmel well details:
&Far CaoprobHDPT or Qosed-Loop Geothermal Wails,having the some You may use the back of this page to provide additional well situ details or wall
construction,only 1 GWl is needed. Indicate TOTAL NUMBER of wells cootruction details. You may also attach additional pages if necessary.
drilled:
.3(dI - f K113MUTAL 1TMUCTIONS
9.Total well de below land wrLoc R) 24a. For Ali WeEar Submit this tam within 30 days of completion of well For adOple welb lot all depdo lW&Mr(eamrplr-3W00'0d2®100') ,tlautrurction to the following:
10.Static water level below lap of casing: 1t/3 1(g�,, Divisio s of Want Resources,Information Processing Unit,
lfw (suet b above raft urc"+^ / 1617 Mail Service Cater,Raleigh,C/ Id{k NC 27699-I617
11.Borehole diameter. pn.) 240.For faieetloe Wens: In addition to sending We fare to ere address in 24a
IL Wall anm aetioo method: .. above,also submit our copy of this long within 30 days of completion of wall
(ie.saga many,able,obese(push,etn) txosbu lion to the following
FOR WATER SUPPLY WELLS ONLY: DivWoa of Water Resources,Underground Injection Control Program,
13a.Yield
1636 Mail Service Center,Raleigh,NC 276994636
(EP m) l Method of tesQ �1 1.4e.For Water SOmmh&latertioa Weilc N addition to ending the lam to
t30.Ditinfeetlon the address(es) above, also submit cow copy of this fmm within 30 days of
b'pa Annual: completion of well conahucdon to On county health department of the county
whew cartsrnrcted.
Form OW-1 North Carolina Department ofEaviomeman l
(2naldY•Division of Water Rerouaa Rewind 2-22-2016