GW1-2021-01151_Well Construction - GW1_20210215

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WELL CONSTRUMONiREP=(GW_.-11 For Tnternst Use only:
1.Weq Contractor Information:
David L. Hardy, Jr. 14.WAT8R2A)NBS =
Well ConmicWN"n FROM
2906-A
>1.
NC wen contractor Cenifimon Number 1s.OUTER CASING f�cautti-used-wells OR LIAM
Aqua Drill, Inc. Flom D s&
®& 11<
buy Name d 16.DINERCASMOR TUBING
L Well Construction Permit#: _ FROM rO u1AMrns [>3t[C7atFs5 MA�tAt. .
Listatl applicable wall catm-otion permin(Le.MC.Cowry,Srott Vwlarae.eta) fL &
3.Well Use(check well use): &
SCIUM Water Supply Well: i7' TO I VIAMEMA swr talctaM MATEO"
Agricultural �MunicipaUPublic R At. IM
Geothermal OleatuWCooling Supply) alt wdetnial Water Supply(single) ; g, R in.
bwus wr—omtntuctal OResrdentiai Water Supply(shared)
i&GROUT'
brip—don I " eAMo
Nowwater Snppiy Well: R R ® /"
Monitoring ReI ovety � R
IN n ft. &
Recharge 00roundwaterRemedl$that
MMORAer Storage and Recovery DSalinity Barrier 'PACK d to
-FROM
Aquifer Test oStwmwrate r DminaEpe . R R
Experimental Technology OSubsidape Control ft R
J.
Geodwmal(Closed Loop) DTMcer - RxLLINGIAG aWehaddl
Geotr MAI Mp0n&Codlmg Retujm) nother ala inunder#21Remarks) ft. ! fL
4,Date Well(s)Completed: _[ ail ID# R
Sa.WeQ Location: .
Fealuy/OanervhmeACC r-ft n?h{afayplccabfa} R A
777
Phya* tAd#s.0%sodZip lye
21.REMARKS
Carroty - Para1ldeotifiNa(PIN)
M Latitude and 1060tode in deg udminnteslaeconds or decimal degrees:
(ifwapold.owe Mang is sufficift) e
3 � 4�7 Nam. �� >a d w
6 h(are)the weli(s Permammt Or OTemporary SiVsVkfvofCerdfiedVeH Cootrsaor
By dV tug dAr farnr,l he-hy that the wall(:)war(wens)coed In aoo r*m
7.is this a repair to an existing well: Dyes or EIN0 wnh ISA NCAC 02C.0100 or 15A NCAC 02C.02W Weft Co unnaton SMzdMft s and dw a
Ifdrtsira repair PH Out kaoum Melt com*=e en ftfaraatt ad aplaJa thanotuneoftha copy ofd*recordhasbaea p vWed to the well owner.
repalrw der N21 m-mw uattou oron dhebackofOdsfbrm
23.Site diagram ar additional well deta0s:
L For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or wen
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER of wells constnsction details. You may also attach additional pages if necessary.
drilled: 'f Lyg j� I®'AL IIVSPRUCTIONS
9 Total well depth below land surface: / 00) 24�For All wells: Submit this form within 30 days of completion of well
Foroadttpto we&hoa9depdoff,We m(estaarpte-3(a)200'axt2 . �s ? to the followi
.�Y °g
E
10.Stalk water lead below top" cm �of ' AP'
Ifwarerlevells above aasbnB use" � Division of water Resoarces;Inlbrmation Ptncesshrg Unit;.
x 1.Borehole diameter. ) ' }•�.8 1 � 2021 1617 Mali Service Curter,Raley,NC 2'f69946x7
s 24b.For b2jection Weft: To addition t0 aen(lnrg 8ta fowl to the address in 24a
method: �t fix+ ��•_ � 'Ww submit one copy Of this foram within 30 days of completion of well
IL Well construction
(i a aoeer.cowy,two.daeetpusb,ate.) c Unction to-the followri►tg
Resomves,Underground
FOR WATER SUPPLY WELLS ONLY: Division 0 Water MM i
Service Center,Raleigh,NC2 6"-63 161 Program,
13a.Yield Wm)0 Method of test Zoe.For ftn&&Ind m J In addition to sanding the fomn to
the
addtesstes)above, also submit one copy of this Imm within 30 days of
13b.Disinfection type: Amount: f9'�- completion of well construction to the(oo'tmfy health depattment of the county
where caiatructed.
Form GW-1 Nw&Corolu*D"xuueat ofEnvimm=ai QWdy-Division of Water Resomen Revisal2 22 2016
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