GW1-2021-00204_Well Construction - GW1_20210125

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i.T CON TRU TION RECORD(GR' 1) For Intamel Use Only:
1.Well Contractor latormton: •�
David L. Hardy, Jr. I&WATM ZONES
Wall Comedy Name saw TO DrC6nrt 'N
2906-A c '�r
'
NC Well Comacror Carifi<arim,lumber
IS OUTER CASING M
Aqua Drill, Inc. IeOM 7D nudata TNIO=
cry Namm ft IL is,7 [ 1 I NER CASING 01t wunmu L
2.Wen Cunstruct /—Construction - ) � 1/ laoM o atA7llatAi.
Lot at,applicable ,ell mrMwoon permin as U1C,Coamy.Ssole.Parana,«a) R R iG
3.Well Use(check well use): IL R id
Water Supply Well: 17.SCRM
MA
Agricultural QMunicipuVPublic O R R oe.
Geothetmd(Heding/Cooling Supply) GResidetttiei Water Supply(single) R R in
ktdustriaVCommercielEIResidential Water Supply(shared) IS.
east To
Noo-Water Soppiy We0: R RYA
J
LGeadmmalfflepungCoolurgRearra)
Recovery R R
QOro r dwataRemediationnd Raevary ©Selinily I1aQi? page TO 1sA'11®uL atplA�r►licrom
13Storom ater Droamp R Rnology ©Subsidmm Conttd R - Rd Loop) ❑Tracer 2L DRILLnVG LOG attar► dsrlBammmyl
in ool' Rtmun 011 er(exulam undo all Remarks) I ELM
R 7 R
4,Deft WeU(s)Completed: a--Well m3 R .,R s d c-
Sg.WenLocation: 7���� [�n�/) .�w
It
rfA'l'll-f f/�LLL_!.� R R
Famliry/Ow Name Facility mefdsppNu6�e) R R
R. R.
Physid City`mdzip R - R
' 21.RRMARRS
Cowry Parcel idmefiotiou Nm(PIN)
5b.Lattode and longitude in degreea/Wnteslsecoads or dedml degrm:
(tfwe0 Noll aye INlooa is aul6ciam)
W cl � _
T
G Ln ` — — `h(ore)the wdl(s)�Permuent or [tTemporuy sittmuaa of beat WeN Cdsa
p„��7.Is this arc 0y so t�date fmm,1 hereby dr rise wdlfs)wa ryarrJ mrmreaed or aaowdm
iprrmen e>vetq walk OYM or ©No wNh led ACACO2C.0100m ISd NCACO2C.0200 WeJlCmanxmmj =&rd,aaddaa
lldn*tro vPdr.)01aa1 kws, WWI ftcffm I*mrllm a adarpdala Wa Hoorn oflhe cq;yoJdb reoo,dhorh mprmldedm Ae we!lowrv,
nparunder 921 nmmrbsmMon am dwbad gfddsfawn
23.Site diagram or oddkioed well data&:
&For Ceoprobe/DPT or,Closed-Loop Geothermal Welk having the same You may use the back of this pogo at provide ailditmml well aft details a Well
construction,only I GW-1 is needed, Mum TOTAL NUMBER of wells cotwtruction details. You may also attach additional pages if necessary.
ar;gea:
QS` SLMMrrrAL EMFL UCT1ONS
Tot9. madae wd4 lMo0depda(fdlfmw(ma
well depth below en w krLee:
Fa mddpl .0 I V if 2N,Far AR Welk: SUIRM this 6 w
rm within 30 days of mpletion of well
e`3®200'and2®1003
�+ earuOntcton to the followirhg:
1&9hlie carat krd below by of eadeg: Divkko of Water Ramwcen,Iahrmtin Ua%
1Jtmwhae!b ataw aorbrg,un"+^ c� :J 1617 Mai Service Cents,Raldgh,NC 276»-1617
11.Borehole dhmeter. _( ,) 24A For iwieedna Well In addition to sending 0se form to the address in 24a
12.Well tosstraeton melded: above,also submit one copy of this fam within 30 days of canpleum of well
atear,may,cable.d'ae<t posh,am.) COMMIMacton to the following:
FOR WATER SUPPLY WELLS ONLY: DMeloa of Water Remoter,Underground Injection Control Program,
1636 Mail Service Center,Rdkigb,NC 276994636
13s.Yield m r
(gP ) Method oftest. / 21c.For Water SwnaW d1 Chester W tw to addition to sendkrg the form to
13b,Dldafeetloa typo /' Amoauh / tldrese(ee) above' also submit one copy of this form within 30 days of
anpkton of well construction to the county health department of the county
where amstruded.
Farm OW-1 North Carol®DryammtofFnvimammtal Qmlity-Division oFWaaRammus Merited 2-21-2016