GW1-2021-02248_Well Construction - GW1_20210722

s ! Pdrtt Form
WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
David L. Hardy, Jr. 14..VYATERZONES' ,.. A.
WellContmetorName FROM TO D
2906 A
NC Well Contactor Certification Number 15..011TER CASING for mtltisised weDa OR'L11�R f
Aqua Drill, Inc. i$oM D TStC[ ESS Ms
ft �l p ft: in. , �il UG
Company Name
/ yJ `SQL//gr /t/1 DINER C/TO OR TUBS � ;..
Z.Well Construction Permit#: FROM
List all applicable irelt co-ftelfon petmfu O.C.fRC.caw%,state,nwimee,etc) R ft �•
3.Well Use(check well use): ft ft is
Water Supply Well: i�SCRBJaI
M TO DiAb�IER BLOTtn7E tFtAlIItUL
Agricultural [3Municipal/Public 0 it ft
Geothermal(Heating/Cooling Supply) . Residential Water Supply(single) 1t ft
Industriai/Connmercial DResidential Water Supply(shared) 19.GRODT
FROM TO .
Irrigation & OUNr
Non-Water supply well: Q K 2 D R Fa,t '
Monitoring Ra ov R
Net on well:
ft ft
Aquifer Recharge DGroundwater itemediatio n
uifer St ay 19.SADID/GRAVEL PACK ble
Storage and Recovery Salinity Barrie FROM TO MATER1" AC86m7i Hereon
Aquifer Test 13Stmmwater Drainage R &
Experimental Technology OSubsidenoe Control ft &
Geothermal(Closed Loop) OTracer 20.'DRiLLiNG LOG attach taidid abeels if
qMMM
Geothetmal(HeonyXoolmg Return Outer( lain under#21 Remarks) FROM TO D m�hodc
ft ft
4.Date Well(s)Completed: Well ID# ft.
S .wen
L�oaaI4 S pi ft.
OR
I
Fac7OamerNeme Facr1 M0(Nappfieable)
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Physical A City.and?rp
County Parcel fdeaffnation Na
5b.Latitude and longitude in degradminutes/seconds or decimal degrees:
(ifwen field,out Iat/long is suffieiew) 22. cello
2 �
. ,03S'714�? N -79 w �t
6.1s(are)the well(sQPen=oent or OTemporary Sig&tfim ofCar"ad Well ° Dam .:y
By signing this form I hereby that the adl(s)war(were)con muward in } ,'t
7.Is this a repair to an existing well: DYes or ONo rrflh 1SA NGlC 02C.0700 or lsA JVClC 01C.0100 WeU Construction&wjdir&and
Ifthis S a mepafr.Apout known wdl cvnonwimm ttformtion and erp/afn the naw a ojthe copyojthis record has beenpmWed to Me wegowns:
repair-der fell remorkrsectfon or on the bock ojt%form.
23.Site diagram or additional well details:
ti.For Geoprobe/DPT or Clese&Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well. '.
construction.only I GW i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBU MITT MUCT10NS
9.Total well depth below land surface:
For nuhtplewegslut all dept&Vdiffe m(onmple.3Qloo•mtd2®100� ( ) 24a.For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static watt'level 6elt►w top of casing: o (fk) Division of Water Resources,Information Processing Unit,.Ijwater level is above rusting tee"+� 1617 Nag Service Center,Raleigh,NC 27699 1617
11.Borehole diameter: 24L For ectien Wells: In addition to)� sending the four 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 auger rotary,cable,direct push,etc)
construction to the following:
Division of Water Resoni ces,Underground Injection Control Program, i
FOR WATER SUPPLY WELLS ONLY: 1636 Moil Service Center,Raleigh,NC 276991636 `
/ 1 +
13s.Yield(gpm) �.®�Method of test J' 7 24c.For Water_S=nfv&1nIM fim ells In addition to sanding the form to
1 the address(es)above. also submit one copy of this form within 30 days of
13b.Disinfection type: L"t 7N Au1�D O completion of well construction to the county health department of the county
where constructed.
Form CiW-1 North Carolina Department of EnvironowaW Quality-Division of Water Resmom Revised 2-22 2016
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