GW1-2021-01104_Well Construction - GW1_20210215

Prim Form
WELL CONSTRUCTION RECORD( W 1 For Internal Use y:
L Well Contractor information:
David L. Hardy, Jr. U.WATER ZONES
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2906 A
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NC wan Comnetorcad{6esdm Number
Aqua Drill, Inc. G[rfgRCABptG �" v'°`�Inrse
Company Name / R
2.Well Construction Permit g: �'—// " C,WYA -,`7Ga(� MATERIAL
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upply Well: 11.u� QMunicipd'hMic R Rermal(lfeatingtodm8 SW*) denial Water Supply(single) R R ra
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So.Well Location:
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Li.Site diagram r additional wall deftem
L For GeoprobaMPT or Clued-Ioop Genhmud WeRn Irv®g the Roma You any=a the beds of this page to provide addidaal wall sin damb or wall
consmwtron,Only IGW-lis needed. hWinto TOTAL NUMBER ofwells rnmomctimdmalls. You may Alan smuchadiilimdpolleeif=many. -
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9.Total well depth below load aoface,_ >
Fo nmldpfewegrlutagdeprMgdoLw,(mmagla.,i-ign..d2oloy) 1h) 36a. For AN WeNm Sufo caommRion m the"tuwingott this form vAddn 30 days of c mpkdm of well
10.Salk waMfeud-blow top of easier. f (h) DhdiMn of Water Renounces,lagr on Proesirs UsR,
$aomrur/uia ter. 1617 KID Service Carter,Raleigh,NC 2709-1617
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Won .j 26h F9L1N1 Io additlam m a®ding the Area to the address in24a
12.�esnatrandon m nbalb /C( i,L a�it�copy of Nis foMm within 30 days of eampledm of well
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FOR WATER SUPPLY WF,LLS ONLY: Dlvleloa of Water Rewmees,Underground Injectlam Cotd d Program,
16M Ma11 Survive Ceuta,Raklah,NC 27699-1636
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13h.Dhinhetloa ban Amoynk the W&aw(es) shove, On submit our copy of Otte from within 30 days of
completion of well aonstrudim to the county health doparmvet of the county
wllme CaORUOwYnal.
Fo mGW-1 Nmth Csogm Depmmem ofFad,emoanrd Qsbry-DiwiMim of WaurRsMonaxv Rawised b21-2916