HomeMy WebLinkAboutGW1-2021-01152_Well Construction - GW1_20210215 Pr�rltFom1 ..
'VMML CONSTRUCTION�RECORD tGW-ll Fo=tmemai use{)01y:
1.Wall Contractor Inform dou:
David L. Hardy, Jr. M WATERZONES
DESCRIFIM
WcM Contract"Na n FROMM � fL
2906-A & ft.
NC Wall Contractor Certification Number 15.OUTER CASING foe azdti-eased webs OR Y.II�IER
Aqua Drill, Inc. !ROM m D MAMMAL
ConPnY Name 16.LINER CASM OR TUBING
2-Well Construction Permit#: _ N FROM DIAhlE1FS IffiQWFSS MAC
Ltat all tapptieable nett tonstnrcNon permlu(fie:�J1C.Comrnt Stag Variance,eta.} '�� � iO'
3.Well Use(check well use)* fL R, tp.
Water Supply Well: 17.SCREENTo DMINIMM tt[oc tgtc s am
Agriculttual ft.
Geoittetmal{He ittglCoaling Supply} JMResidatt i darter Supply{single}°< fL M in.
IndustrieYCommucial DResidentiel Water Supply{shared) 1st GROW,
ra To et Aaro
Plan-Water Supply We11t fi: 4
Monitoring Rwomy & fL
Injection Well: ft. fL
.fer Recharge DGmundwaterRainediation
er Storage and Recovery C)Salinity Barrier mom'PACK MA
Aquifer Test OStomowate r Drainage R fe
Fxperimental Technology OSubsidenae Contra!
Geodumnal(Closed Loop) DTMcer X DRUJANG LOG attaehaddlil a d sheets ff nevessitrA
Cidd#terutal satin o01' Return) n0ther lain melar#21 Remarks FROM To
j fk. f! ,zE
4,.Date Wtdl{a)Completed: _` ell!D# fL ft r GI'leiMi—
Sa.well l t,ocyatlon: ft
Fact~ 7nylOwner ( // �� aefiity LCfO fefapglitahte} fL R-
F�f f. fL
Fhysioa A*ess.City.nerd Zip
rs 21.REtNARILS
County 1'eraelidenti6eatioallo.(PAS
Sb.Iattttnde and longltade is degtxes/tniatttes/a+ecoads or decimal degrees:
0fw Id.out iatlleng is soffieiew)
6 h(MV)the weA{s}j; Permanent or DT*u porary SiNuxii ofCordfed well Coaaaaor
By$W09 dis farm.l hereby that the well(,)was(..)ova&WW In aoa,U-
7.Is this a repair to an enlisting Weil: E)Yes or Flo with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Co nnadlen Sra»darde and that a
If this 8 a repair fiat out Maim well coaxonwmr lonnadmiilmdespho dremme efdx copy ofthtrreem d has been pmrtded to#a well vw7w.
repair wider#21 remarkssaWon or an the bukofsft inm. "
23.Site diagram oradditiomtl well details:
S.For Ge:aprobeMPT"or Closerd-Loop Grealhermal Wells laving the same You may use the back of this page to pmvide additional well site detaals or well
consbncdon,only I GW 1 is needed. indicate TOTAL NUMBER dwells construction details. You may also attach additional pages if necessary.
drilled: 3UBMLTTAL INSTRUCTIONS
9.Total well depth blow land aarfaee Ig epF Submit this form within 30 days of completion of well
For multiple wellslEstalldeptln{jdfjeretu(amarle.3(a}2,00•arutl 1p0 ,. � on to thefollowirtg
10.Static water level-below to of EhQ ° i
p easing: {ft:) Division of Water RebaurCear Iufbramation Processing Unit,.
lfwater level is above cw t$use"+^ r 1617 Man Service Center,Ralf,NC 276"4617
11.Borehole diameter.. �� 1 5 2d�1
fln�) 24iectloa YY'e4x in addition to sending the farm to the address in?Act
LZ.Well construction method: Q G['s "_,a ��Y3't' f submit one copy of this f�:within 30 days of completion of well
ai.e.augur,totery,code.directpaah,W.) Water Resouicei;,Undund Injection Control
—"T ;" ^^:"it��1 trctron tolls fallowing
FOR WATER SUPPLY WELLS ONLY: Division of 1636 Mail Service Center,RReldgk N 6991-636 gym!
13a.Yield(gpm)0. f Method of or Water Sunph,&Injection Wells: In addition to sanding the form to
a the address(es)abova, adw submit one copy of this form within 30 days of
13b.Disinfection types Amount: 4 -- completion of well construction to the'countjr health depaitmcant of the county
whiarecamstru tell.
Form OW-1 Noah Csmlbm Dapslduent of&vno==W Quality-Division of Water Rawwm RevbW 222 2016