GW1-2021-01150_Well Construction - GW1_20210215

Prl"t•Foirrl.
WELL CON UCTION RECORD&W--11 For btemat Use Only.
1.well Contractor loformadon:
David L. Hardy, Jr, 14.WA NIBS
Well CownwrNAM
2906-A ft. ft.
NC Well Cmu mor Cadfinfloo Numbw M QVM1t CASING farm 0R'Idt=
Aqua Dri1I, Inc. D
C*mM Name
���� I&INNER OR TUB=
2.Wag Construction Permit tl: TO
loaft,Vpllcable rrdl cammeu-permrtr(i.e.WC.Como&St^*ioace,acJ ft ft.
3.Well Use(check well use): ft.
Water Supply Well: i7.SCRBStt
>aA
Agricultural DMWc**?dblic 0 ft ft, in.
Geothermal(Fleating/Cooling Supply) jBResideatial Water Supply(aingie) —ft e. 10.
Industrial/Commenaal E3Residen w Water Supply(shared) IL
Tai on
Non-Water Supply Weil: fL
Injection Wen:Manito
an 4
1t ft,
Aquifer Recharge �QroundwaterRediation
Storage and Recovery 13Salinity amor P U& to
quiter Test �Stormwater Drainage ft. ft
Experimental Technology Subsidence Control it. ft. '
i
Goodwoull(Closed Loop) CITracer FROM
4addldeaat if
t3eodtermat ooh Rehm Odin( lain under#21 Remarks
4.Data Well(s)Completed: 2 e1,�1 well @t!U Well Lo�fion:
Faa►1tp10wsurNeate ityIDO(ffapp6Oabte} R
aad2t 27&V-3 ft; �.
S at.RStY1ARKS '
Coomy FareetldtatifiNa(PtN)
W Ladfude and longlimle In degeeestmiautWacconds or decimal degrees:
(ifweu 8e14 one lat/lona is su icied) cutler•
b.ls(are)the�eeWWAC1Fermammt or Temporary SrBmuae of WeU I?ate
Is this a re S sy srgntng ft M,t he that drr.�et!`w��►avnrm d&f aaamdanae.
7. pair to an esisdn welt: Yes or QNo wuh 15A NGtC 02C.0100 or 15ANCAC 01C.0200 Well Cbnsfnxtan r mrd&ar a
Iftirisfs•arepmr.ftnmtAn »wdlonramrralan ly'brmatto»and eplaln the name ofthe aw 4fthis reewa has bow pmvtded to drewell awner.
,eparr ands s21 nspwh secdon or on rk back of ddsform .Site diagram or additional well dehtiiss
S.For Geoprobe/M or Closed-Loop Geothermal Wells having the setae You may use this back of this page to provide additional wall site detail or well
conshuction,only I G -I is needed. Indicate TOTAL NE MBls"It ofwalls construction details. You may also attach additional pages if uecomy.
drilled: SUBMYITAL g1IICTIONS
9.Total well depth below land smbr (ft) 4a.For Ali Wails: Submit this form within 30 days of completion of well
For mdxpkwe&1walfdepft,V,&&rwx(aaatepla-3W00'orbd2 00ry.
� ? on to the foA �owin
10.Static water herd below top of cashtg: Division of Water Resonrtxs IgPormaHan Proms Unit,-
Ifwatarlevel is above use"#' f (1 1617 Ka Service Center,Raleigh,NC 216"-1617
11.Barebole diameter: (ra.) E� 2U24h,For,jiltection Well In addition to seeding the form to the address in 24a
submit one copy Of this hen within 30 days of completion Of well
IL wen conahuctiOn method: onto the following:
(i a auaar,somsY.a disectg eta} 9 IA") I
Division of Water Resources,Underground liu*fion Control Program,
FOR WATER SLIMY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 09-1636
13s.Yleld(gpm) lJ Method of loaf: s 24e.For Water Suuniv&InlUflon Weil In addition to,sending the farm to
13b Disinfection tho addresses) above, also submit ones copy of this farm within 30 days of
b�pct Amoani: completion of well construction to to county health department of the canny
wham constructed. '
Form GW-1 Nm*Cm lim Dopman efF.uvh===W QwWy•Division ofWdwRmam m ttovind2 22 2016
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