GW1-2022-01144_Well Construction - GW1_20220103

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WEI,,I.CONSTRUCTION RECORD(GW-1) For Intemel Use only:
1.Well Contractor Information: -�
David L. Hardy, Jr. 14.WATERZONBS
Well Cout actor Name FROM TO DSSCBII�[ION
2906-A It Gel
& fL
NC Well Contactor Certification Number
BL"to
Aqua Drill, Inc. FROM!�GUTERCAsnvG fitWeb)OR-I.»
TO 'FII ffi 11fA
Company Nameft
lG.1NNER CASING OR TUBING dosedaoo
.z
2.Well Constriction Permit#: � _ 1 FROM TO nrAaErFR ffiQQgL ;?
Ltrr al!applicable"WI—auction perm,u(i e.WC.County,Sratg Ya►lamw,etc) & fL in.
3.Well Use(check well use): & ft in,
Water Supply Well: 17.WAISM
Agricultural FROM Ta nrA> sroTslz� ffitas MATF3tFAt.
�Municipal)Public Q it ft 1n.
Geothermal(Heating/Cooling supply) DResidential Water Supply(single) & R in
IndustriaUCommercial nReside rdial Water Supply(shared) G .
IL GROUT
"brigation FROM i+D IMEMD Mi0
Non-Water Supply Weil: - e
Monitoring _J31tecovery R &
Injection well:
tGoAquifbrTest
uifer Recharge Groundwater Remediatimt R -
trifer Storage and Recovery Salimt3'Barrier 19•SAN NGRAVEL PACK if a cable
FROM 110 11tATF7tW.oStorm Dr
waterainege ittperimental Technology D&Wdence Control & ft.
othertnai(Closed Lttop) 0Tiaeer 20.DRILLiNGLOG attachaddifiond sI ifothermal('Heating/Coolmg Return) nOther(explain under 421 Remarks) TO
// tl: IL Gl�Z.
4.Date Well(s)Completed: 2�AVeli ID# fI
Sa.Well Location: ft "-
1401
FagGty/OwnerName / . 1D0(' applicable)
& f
r' I -
21.REMARKS
Countyr Pmoe!Identification No.MN) N 0 3 7
5b.Latitude and longitude in degreWminutes/seconds or decimal degrees:
(ifwell field,one latl ng is sufficient) it
22.C lion: �L
N "�G ;llr��lr�ai Bf���CSI�iG l)`II'
T212,11,
6 is(are)the weA(s)j§Peruu neat or I et�rorary S; Certified Well Contactor
Date
BY OVIng this form 1 hereby the well(s)wan(awe)a isirudYed In anwrdmee
7•Z+this a repay'o an "wellcdsdn well: Yes or 0 W*1SA NCAC 02C.0100 or fS CO2C.0200 Well Conmrralon Smmdmdrmid thata
Ijrhls is a rnpa/r,JU1 out bwrm well aonstruetton laformar! mrdesp/at»thenaume ojthe caPyofthu recordhaabeui p ro the wolf owner '�
repairwakrF21 mma►IasectionOran dw had offtjorm
23.Site diagram or additional well detaffs:
L For GeoprobeMPf or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW 1 is needed. Indicate TOTAL NUMBER ofwells construction details.You may also attach additional pages if necessary.
drilled-
,� SUBMTITAL RMUCTIONS
9.Total well depth below land sarface: , (ft) 24a.F r All Wellue Submit this fomu within 30 days of completion of well
Far-dd le wells ltrt oll de the i p P P jm�etrnt(emmple-3(a�2 a,�2®r009, construction to the following:
10.Static water level-below top of casing: (fL) Division of Wafer
rat Ijwalw level Is above ta2t/a&rae"+^i Resources,Information Processing Unit,.
6 1617 Mail Service Center,Raleigh,NC 276991617
ll.Borehole diameter. Cm.) 24L For Injection WeiLLr In addition,to,sending the form to the address in 24a
IL Well construction method: ��� above,also submit one copy of this form within 30 days of completion of well
(i a auaer.rotary,cable,direst posh eta.) construction to the foUowirtg f
FOR WATER SUPPLY WE ONLY: Division of Water Resonirees,Undergrouad Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
13s.Yield(gem) Method of test d 24e.For Water Suonly& iectio+wens. In addition too sending the form to
13b Disinfection147
the addresses)abo� 81W submit one copy of this form within 30 days of
IYPC Amount: completion of well construction to the,county"health department of the county
where constructed.
Form GW-1 North Camtica D epmosoatofl3mmamaeatei tZaality-Division of WaterResouaces Revised 2 22 20l6