GW1-2021-00248_Well Construction - GW1_20210125

Print Forme:--:
WELL CONSTRUCTION RECORD tGW it For Intemaj Use Only.
1.Well Contractor Information: - •-
David L. Hardy, Jr. 14..WATERZONES'
Well ConnaaorName FROM TO a
2906 A 0 zr
NC Well ContractorcmficationNumber 5 I/ /14
15..OUTER CASING form O 'LINER
Aqua Drill, Inc. FROM TO Di4NWM; •,RICKKESs
Company Name & ft.
2.Well Construction Permit#: .� FROMC G'OR TUBING
1N d MATEUM
IMall applicable irdl catstroction permits(Le Ultra CoM1y,Stop Variance,ere) & & in.
i
&Wall Use(check well use): ft ft.
Water Supply Well: 17.SCREEN
AgriculturalluniClp81/PUb11C OFROMR DrAlllErl�t ) MATFRiAI,
Geothermal(Heating/Cooling supply) GResidential Water Supply(siagie) R ft in
Ltdustriai/Commercial tjItesidential Water Supply(shared) I&GROUT-
Motion FROM TOEMPJACEMEPfr
Non-Water Supply Well % 17
ft B
Mcrlitoring Recovery R IL
Injection .
ft. ft. '
Aquifer Recharge 130roundwater Remediation tg,SAND/GRAVEL PACK d k
uifer Storage and RecoverySalinity Barrier FRAM m MATHtW. Eefpt ac�nFxrMB[BOD
Aquifer Test OStormwater Drainage, R. ft.Experimental Technology 0Suhsidence Control tt ft.
Geothermal(Closed j
�D) ��Tiacer Z0.D LOG attaeL a tonal sh"if
Geothermal eatin ool' Retnm Other( Isin under 1121 Remadcs) FROM TO ee10e 'O
R
4.Date Wells)Completed: W. Well 1D# & BOG
,##.,Well Location:
ft. ft.
Feadlity/�OmwNaau Facilrtytpg(ifappiicaile) ft. ft.
—=1-- " 4 f/// R
phpic t c y.and Zip D ft. o-
21.1tEMARIfS
Coa°ry �_i Porulidea66cationNo(PW)
5b.Latitude and longitude in degreewminutes/seeonds or decimal degrees:
(ifwell ficK onecatigm laNlong is sul$eieat)
w �
6 h(are)the weli(s)OPermanent or OTemporary Sigmatre of(ViMed Well nhsaor '! h
By dV tg this f 6rm.I hexby t/an the wells)was(Were)aonstroetod to aeowdanee
7.7s thin a repair to an gti6ting well: QYes or ONNo wuh ISA NCAC 02C.0100 or ISA NCAC 02C.02M Well Comanetlan S'amdmrfs w d that a
Ifthis ts a-pdr,fin owk mm well ton&=don Irp'rormwlon and eplakn Ike ndnrr ofthe copy ofdds mewd has bear provided to the wenoamer.
-pairamler b21 remarkssftwm or on the back ofrhisform
23.Site diagram or additional well details:
&For Geoprobe/DPT or Qosed-Loop Geothermal Wens having the same You may use the back of this page to provide additional well site details or well
construction,only I GW 1 is needed. Indicate TOTAL Mom of wells construction details. You may also attach additional pages if necessary.
drilled:
QC~ SUBL INSTRUCTIONS
9.Total well depth below land surface:_ /V✓ rg y
? Ohl. We Submit this foam within 30 days of completion of well
ForrradHple wells liuoll depths jdtflerenr(example- mrd00 2@1001 ♦� "�+�9 ' w on to tfie following
10.Static water Ifrd below top Of casing: �'o- � (R) �Oe�'� Division of Water Resources, Processing:lfwaterInd is above emhr&rrx'+^ Information Unit,.
A\ t a,X$17 Man Service Center,Raleigh,NC 276991617
11.Borehole diameter: nnA INN dry
11n • In addition to sending the form to Lire address in 24a
12.Well construction method: ^fi;,�� submit one copy of this fob.within 30 days of completion of well
(i a anger,mores:cable,ducat posh,etc) Cohisl
ruction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resouiees,Underground Injection Control Program,
1636 Man Service Center,,Raleigh,NC 2769916M
13a.Yleld(gpm) Method of test: r 24c.For Water Supply&In_teetion 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 �construction to the oouMy health department of the county
f
Fomlow-1 Nm&Camliva Deportment ofEnvimamordal Qaalfry-Division of Water Rasearces I Revised 2 22 ZR16