GW1-2021-01141_Well Construction - GW1_20210215

Pihirt On.
WELL cafffin6u.- t`I.r BNB ZOM w -11 For Ia mal Use y:
1.Wen Contractor Information:
David L. Hard, , Jr, 14.WATERZQNSS
Wellconbactaft e " SE=
2906-A `- 47
NC Well Conumor Canification Numba i5 GIr1BRCA SIN G O>;'Z
Aqua Drill, Inc. mom TO jolgw=
Comp W Name ". f. IL -7 I 1 UZ-
2.Welt Construction Permit#; 4E/ O�'l G �! iNNitR OR e
GftJ ail appttcabta me11 conrrtrretfo»permfts(te 07C Cax»tjb Stote,Vorimrcu,eta) h &
3.Well use(check well use):
Water Supply Well: 17.
Agricultural �virmicipaUpublic Q ft: ft; IL
Gedtemmaf(Heat*Coolmx Supply) _Mite~aiderod Water Supply(bungle) g, a, to
IndostriaUCommercial E)Residentlat Water Supply(shared) IL
GROUT
IVoa-Water Supply Well: ft6 IL dc-f
caitorwe Rena>ti
fit fb
Recbup 130mmndwaierRetnedlelion
l4.SAIVDiGRA. PACK f
Stomp and Recovery Salinity BarrierFROM ., TO MTiVit1.
Aquifer Test OStonmwater Dminow
Experimental Technology OSubsideaee Control ft. ' fir
Geothermal(Closed Loop) DTMM 2L RIMMI IA6 atmehaWficaal N
Gethermal(Head ool Remm Otha( l—waundw#21Remarks " '0MENMEMea:
tic {. &
4.Date Wells)cemplehat��Well ID# fL 9,0 L
SL MOM Locaflo'n.�* !c t
r�' r"rl. �t�1 i fft ft
FamliW10waerName M#GrOMMMO ft ft.
1131(// 41�'-It,lh '0 t rl/
*p d Address.City,and Zap.-/ .SZ 73 '70 ft &
� � Z1,RSAIARKB
Cou* Paralldeati5eationNo.(PIN)
5b.Latitude and longitude in degeaesfnnlnahslseaonds'or deelmai degrees:
(ifwetJ Heil ono laUlaag is aa@laieat) 22. leatiah
6.b(are)thewev(SAWermane nt or DTemporxry ofCcrnfiad W Canna Dam
a s BY String this,jbm 7 hereby *at the events}=w OwO ambutted to=wMan-
7.h this a repair to an existiag well: DYes or o q SiANCdC OX.0100 or 1SANC.ICOJC.020O Weil Consandm Saemb*mid*w a
7jthlsEra tepatr fiAo»ttvtmr»tigdt taahatruettcet lt�tr»»attaJaade yplcth the pa of tie L I�4 1 this recardko bso pmvtded to thewell o mp.
repafrander e27 MmrnAsser oro»the b taftMs jernx glaljism or additions1 well details:
L For Geo belDPr or Closed- u. pap to pro Loop Geothermal wells�gttfEe �� :tond�siLsYoudmiays also attach add�mm or well
conshnction,only 1 OW-1 is needed. Ltdieate TUTAL NUMBS ofv }` . ,
drilled:
anal pips
,�l71lMg"PAI¢�Iyi . I ,NS
9.Tots!well depth below lead sur3ace: � t L) 24a.Far All Wefts: Submit tas form within 30 days of completion of well
For r»rdrrp7e waft ttstaJtdap>ter{tjdf,
Pot(eral»pI-3@2001-d.?@IM �antothafollowin�
10.Static water favel•below top of caster: ZA0.__._.,�..(ft:) Division of Water Rewurtxa,Information Processing Uf t,.
jfwater tow b above oatft»se"+"� 1617 Mae Service cenhgr;Ratetg6,NC M6991617
]!.Borehole diameter: ) 24b. or IniQp�►�a: lA addiction to sending We form to tiro address in 24a
Ix Well canstractlon metLod: above,also submit one copy of this form within 30 days of eomple ion of well
(f.a.angar.�y.aaWdkwpusb,eto.) a tothefollowung
l'livLaion of Water Resaoitxs,Uadergrannd Injaetiloa Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Cater,:111*1 h,NC 276991636
13L Yield(gpm) , 1NieWod of test � 24c. � In addition to sending the fawn to
the eddnrss(es)-above, also submit one copy of this form within 10 days of
13h.Dhdafeetiaa type< Ames ZI pttetilm of well contra don to the enemy hee1Wdeparbacut of the county
where canshucted.
FomrOW-1 NortkCeroliaaaftsavi:aammytalQmdity•Divlci�ofWataRaaomaa Revitad2 22 2018