GW1-2021-00356_Well Construction - GW1_20210127

Prlrit Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David L. Hardy, Jr. 14:.WA11MZONes
Well Contractor Name FROM TO DFSCRQ'1T0
2906-A
NC Well Contractor Certification Number "z
MOUTER CASING formal&cased wells)OR'LINSR fa'
Aqua Drill, Inc. FROM D , MA
' ft. is
Company Name
2 e Z4 16.1NNER ING'OR TUDIN closed4bo -
2.Well Construction Permit#: PROM TO I DIAMEM i I TR7CKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,stat4 Irari mce,eta) R
3.Well Use(check well use): & R
Water Supply Well: 17'SCRM
FROM TO DUMEm—m 7sI(y1'b'II£ TMCIOMN MATERIAL
Agricultural OMunicipaltPublic 0 ft. &
Geothermal(14eating/Cooling Supply) FoResidentiai Water Supply(single) ft. tL
Industrial/Commercial OResidential Water Supply(shared) 1g.GROUT .
irriation PROM TO MEIHOD& O
Non-Water Supply Well: ft. 2- tR
Monitoring Recovery & &
Injection Well: & %
Aquifer Recharge Groundwater itemediation
. `19.SANDlGRAVSL PACK d bk
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATMIAL EMPLACEMENT➢RsMOD
-Aquifer Test OStormwater Drainage R &
Experimental Technology [3Subsidence Control R. ft.
Geothermal(Closed Loop) OTracer 20:DRILLTNG LOG.ittaeb addl&onet alroets tf
Geothermal(Heatin oolf Rehrm) rjOther explain under#21 Remarks FROM TO D N edw nuirock ere
& &
4.Date Wel(s)Completed: Well ID# QfL
SR.Well Location: dL 7 Q fl,
Facr7ity/Owner Nt& Facility MO(ifappiu able) R
�� � /� 8. R
P�pical Address,City.and Zap ft. R
2L REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude In degrees/mtnutes'/secends or decimal degrees:
(ifwell field.oar Mang is sufrxient) 22 a n:
N
.�' . SignatmeofCertifiedWe11Cor or —� Date
6.Is(are)the wdl(s)OPermsnent or Temporary ': :i -
�8 thus form.l ref y cer0 dw the we!!(s)was(were)r.�onsh►rcied in oeeordmrce
7.IS this a repair to an erristing well: Yes or o 11 W1 ft
02C..0100 or 13A NCAC 02C.0200 Well Construction Manda►&and Ow a
If#&is a repair.Jill out hmwn well construction lrformatlon esplatn the nol to copy ojtbts record has been provided to the well owner.
repair under#21 remarks section or on the back ofthisform 23,;Site;diagrem or additional well detar7s.
8.For Geoprobe/DPT or Closed-Loop Geothermal We1D havipg.the same 'You may use the back of this page to provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary_
drilled: ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:_ / J (ft) 24a. For All Welter Submit this form within 30 days of completion of well
Formuhlple wells ltstall depths ijdiiff&-wt(erample.37760
2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ijwarer level!s above caring use".+^ 1617 Mail Service Center,Ralelgb,NC 276994617
11.Borehole diameter. (m. 24L For Iaiectiion Webs: In addition to sending the form to the address in 24a
12.Well construction method: a f' e I above,also submit one copy of this form within 30 days of completion of well
(i.a auger,rotary,cable,direct past,etc.)
construction to the following:
Division of Water Resoni ces,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Si 24c:For Water S000ly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount:, completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22-2016