GW1-2021-00362_Well Construction - GW1_20210127

Print Form''.
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:- ! '!
David L. Hardy, Jr. I4:WATERZONES
Well contractor Name FROM TO 1) N
2906-A ft. o ft.
NC Well Contractor Certification Number M OUTER CASING for mnttitaaid yseDs`OR'I.ITIER
Aqua Drill, Inc. To D •
ft f! ;in.
Company Name _ V
16.INNER CASING-OR TURIN97geotherind close"am)
"
2.Well Construction Permit#:1/�/ /r// ' Gt7�J '20 !� FROM To Dry I fficttrrt sS I MAMMAL
Liar all applicable well rn»strocrion pe its(Le UlC,County State Varlonce,eta) & &
3.Well Use(check well use):
ft. & is
'T
Water Supply Well: `17.`SCREEN
FROM TO D14NW at .SLOT SEM I THICENM I MATFATAL
Agricultural QMunicipal/Public 0 tt f! In
Geothermal(Heating(Cooling Supply) ,Residential Water Supply(single) ft. R in.
_ Industrial/Commereial Residential Water Supply(shared) IB.GROUT ...:
Irrigation FROM lO Fd4tpLA mum&AMOUNT
Non-Water Supply Well: t fL
:)Monitoring ORecovery R ft
Injection well:
R ft.
Aquifer Recharge Groundwater Remediation -
i9.SAND/GRAYBL PACK d ble
uifer Storage and Recovery DSalinity Barrier PROM To MATERIAL �aipLAr MertaoD
._•Aquifer Test DStomawattx Drainage ft f!
Experimental Technology OSubsidenc a Control & & '
Geothermal(Closed Loop) OTracer 20.DRII.LIIHGLOG.attachsttditiosalabeablf
Geolimemmal(Heatin 'Return Other lain under#21 Remarks FROM TO D edw coati A eta
! R e
'4.Date Well(s)Completed: ',1, I__ well ID# ft
r,, A,
$a.Well Location-
/ A oft
R &
Facility/Owner Name Facility IDD(dappiicable) iL &
A' Al- � R
Physical Address,City,and Zip � R ft.
21.REMARKS
Cody Parcel ldentification No.(PIN)
5b.Latitude and to tude,fn.d ``ngi egrees/minutes/seconds or det3mal degrees:
(ifwell field,one Iat/long is sddletem) -- 22. cation
6.h(are),the well(s"ermanent or OTemporary Signenae ofCcrtified Well
By.sigtting this form,I hereby cmb that the wells)was(were)cotutiucted in accordance
7.Is this a repair to an existing well: DYes or MNo c" ivith 13A NCAC 02C.0100 or/SA NCAC 02C.0200 Well Conmuction&andar&and that a
ffthis it a rVon fill one brown well co s"ictlon information and esplofn the n,&m ofthe' cqVqf1h1s record has been provided to the well owner.
repatrunder#21 remarks section oron the bock ofthisforaL
1. ite diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having 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 NUMBER of wells construction details You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7c"�I 00 24a. For All WeOs Submit this form within 30 days of completion of well
For mrdtiple well;I&I ell depths ifdirjerent(example-3Q200'and��2®100) construction t0 the following:
fw ter level
watt'level beltw top of easing: UP Division of Water Resources,Information Processing Unit,
Ijwater level is abate cacti&use +^ 1617 Mail Service Center,Raleigh,NC 276"4617
11.Borehole diameter. > y(in.) 24L For Inlection WeRS In addition to sending the form to the address in 24a
1L Well construction method: above,also submit one copy of this font within 30 days of completion of well
construction to the following:
(Le.saga:minty,cable,dircctpaah,do.),
Division of Water Resources,Underground Injection Central Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699 16M '
139.Yield(gpm) Method of test: ' 24c.For Water Sonniv&Infection Wens: In addition to sending the form to
the address(es) above, also submit one i copy of this form within 30 days of;
13b.Disinfection type: AmaVat: Ik ® completion of.e 1 construction to the county health department of the county
where
Form ow-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2 22 2016
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