GW1-2021-03631_Well Construction - GW1_20210823

Print Form
WELL CONSTRUCTION MCORD,(GW 1) Far Internal use Only.
1.Well Contractor Information:
David L. Hardy, Jr. X14.-WATMZOMS
Well Contractor Name TO - D N
2906-A NC Well ContmctorCotificationNumber IMM
Aqua Drill, Inc. FCT G fa: Mess OR'
FROM TO r DWXM MHOOM IMA
R ft+
Compaay Name
I(r.QtNER CASING ORTO8ING o0
2.Well Construction Permit 4: ' J�G D 2d roots To : MATffiAt.
Listall applicable irell caarouction permits(Le.UIC.Cmatry,State,varimice.etc.) R & in.
3.Well Use(check well use): R R in
Water Supply Welt: 17.SCRtiEN
Fn M TO DIAME1tr'2t S=Suz ffiGBNEBS 11tA7F.arAr.
Agricultural [3Municipavpublic 0 & tt in.
Geothermal(HeatingJCooling Supply) Residential WaterSuppiy(single) g, � in.
R1ndusftWComnt=la1 OResidentiai Water Supply(shared) i&GROUT
• rents To Enn=1w AMO
Non-Water supply well , tti !J
Monitoring Recovery R tt
Injection Well:
tt tL
Aquifer Recharge 13GmundwaterRemediation
79.SANUIGRAVEL PACK fifa ta
uifer Storage and Recovery OSalinity Battier mots I To MATEKIAL I BMPIACEM 1 METE OD
Aquifer Test E3Stomnwater Drainage R R
Experimental Ter.hnology OSubsidence Control % ft.Geothermal(Closed Loop) OTMW 20.DRII.LIl�iG LOG attach addifiotwl sbaeb iP
Geothermal(liealing/Cooling Retam) nOtha(exphtfri ander#21 Remarks) mum To DB6CalPiiaN or hudces.solUsadc a�
@' !r
4,Date Well($)Completedj--- — •- Well Mo Gj
So.Well Location: !3 x `•'L
FaeilitylOwrnnrName foei4ity/#DO{=fapglieabte) R &
ft
ilk eel J 1 A�7YBn AIX 22 zf
Physicd Addresss..�C`ity,,/� & ct.
Zip �r J
JJ�-�I✓1 L/� 21.RfiMARK5 �.,
t
dtmw 1'arsct1demifi=tioallo.(PRE!)
5b.Latitude and longitude in degradminutesisecoads or decimal degrees:
(ifwefl field.que laffl on8is suffictierd� ) 22.C bon: .
yr �f N (, W
6 h(are)the well(s)&trmaueut or OTernporary Sigmiwe afCeiai well Conbactar Date
7.IS this a BY stoning this form,I heady coo dart the m*(s)vas(sere)cxuvu led to aacmdmw
repair to an existing well: OYei or �io udth ISA IYCAC 02C.0100 or ISA NCAC 02C.0200,Yell Conatuertomn Shmd rds and that a
Ifthts is a mpatr fill am Aamm well aonsnuction lrformattan indewlath thenamre ofthe coNafth&mcard hasbem ptovidedto the well owmrr:
repatrutuler 921 mmarbsectiom oron the back ofthlsfarm.
23.Site diagram or additional well d_eta#ts:
&For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well.
construction,only I OW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pies if necessary. I
drilled: sIIg�1�AI INSMUCTION3
9 Total well depth below land surface:' _:.jam) 24a.For AD Weir Submit this fora, within 30 days of completion'of Well
Formalrtple wellsltuart daprhr!rdt-fferent(emm4ie-3 a@200'arn12@100') construction tothefollowing:
10.Static water htvei•belerw top of casing: �c7 (tL) Division of Water Resources„Information Procett,4ing unit,. -
Ifiraterlevel is above fin&ase"+" 1617 Ma8 Servke Center,Raleigh,NC 276994617
11.Borehole diameters utGh) 24h.Far intectimm Wpg: In addition'ta,sending the fomt'to then address in 24a
above,also submit one copy of this foram within 30 days of e�aapletion of well
12.Well coasbrnMtaa method: "'&/k construction to the fw0wi,is
(m auaa.rotary,cable.dampusb,arc.)
Underground Inje
Division of Watts'Resouirces, ction l:a -PPogram,
FOR WATER SUPPLY WELLS ONLY: 106 Mail Service Center,Raleigh,NC
13a.Yield(gpm) Method of test 24e. W . In addition to w ti form to'•
the address(es)above, also submit one copy of this fonii ithal 3o of
13b.Disinfection we /1 Amount: l completion of well construction to the county health departmemN1)''' county '
where constructed. f }
Form GW-I Not&CamhoaDepmM=ofEatmammemtatQudity-Dram(nofWaWResomces Ravtt�d;2222016 f