GW1-2021-02689_Well Construction - GW1_20210805

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WELL CQ NSTRUCTION RECORD-(Gw it For Intemal Use rally:
1.Well Contractor Informadon:
David L. Hardy, Jr. I4.waTSR7A)Nfls _
Well Connector Name To n7 rlcet
2906-A i!tft. `�
NC W#U Caatraator Certification Number 15.OUTER CASING far xpnld msd mks pR I.BM
Aqua Drill, Inc. FROM >� D , TatOOMS �► r
Company Name Z.R' In. ,
CL��" �1' 2-1 26 C
2. AS OR Ti3BiNG d .77
Wellroans TO nw+ta�a i iffiCraal�ss MATERiAL
Ltatant applicable ire[/conaruedon permtrs(Le UIC,County.Sime,Varlow.#ter) `
3.Well Use(check well use): fL fL f0'
Water Supply Well: .47.SCREEN
P"M I TO 9= MMMMIESS I MA
Agricultural DNMnnicipaVpublic O t fL ln.
Geothermal(FleetbVCoolingSupply) fflitesidential Water Supply(single) g & 10
IndustriaMmum elcial nResidentisl water Supply(shared) IfL GROUP
FROM TO 1 Q
Non-''Water Supply Wells ft: & r ' Q
Monitoring Racovcry fL M
ugationwell: fi
Aquifer Recharge 0(houndwater Remediatian
Wfer Storage and Recovery DSalinity Barrier MGM TO PaC1I dMaA�" M to
Aquifer Test ElStmmwater Drainage &
MT
Experimental Technology [Subsidence Control R "
Geothermal(Closed Loop) E)Tracer -21L DRUJ.JNG LOG attach aMdo d sheath ff
GeothermaM(Heath poling Retain Qdher lain� der#2M Remarks) kOK iL4.Date Wdl(s)Completed:(�n 2 2 Well 1D#Sa.W 4lLocation:Naasa Faeifity1lTfk{ifagplimbte} ft.
RE EIVEC
P"MMdresk City.-d zip
21.REMARKS . .
e4tin '�4 46e ._._.._ . ;
County M11112
Sb.Latitude and langltude in degradminatealmonds or decimal dam:
(ifweu field,one lattlong is suf view) cad
S L d N 7?. 11 �` w 2-
6.Is(are)the we11(s}&ermaneat or DTemporary
si-VA me of Certified Aron CM-cm Data
By stgnfng^11*forn41 hereby ere*that the udl(a)ram(rare)amts&UOW to maavtdmrae
7.Is this a repair to an existing wdl: EjYes or Jallo wnh ISA NCAC 02C.0100 or 15A ACAC 02C.0200 Well Cwnrmatan Srond vdr and that a
IfthtsPia-pafrffUamkrtmmwelibmtsmwhmImSmattmrandewlaftoenamrrof/ha copy ofdris record hw been pwdedtathewellmow.
r# r wa 921 remarbwdwn or on the back ofthtsforn.
23.Site diagram or additional well details:
L For Geoprobe/DPT or Ctose&Loap Geothermal Wells baviimg the same You may use the back of this pager to provide additional well site details or well
construction,only 1 OW-1 is needed Indicate TOTAL NUMBER of wells construction detail& You may also attach additional pages if necessary.
drilled: c;'` UB�1NS7tU ION3
9.Total well depth below lewd surface: r / �(fR) 24a.For All Weiss Submit this form:within 30 days of compledon of well
Formulliplewe&Ibialldepfhriftit•,j—t(=-0-3@2001-d2@1W) consbuctiontothefollowing:
10 Static water level below tap of casing: "T p (B.) Division of Water Resources,Iiaformation Processing Unit,.
j('xwlerlevef u above carom we"+" 1617 Mall Service Center,Ratelgb,NC 276991617
11.Borehole diameter. e��°
Cm. / 24b.Far inicctirrn Wells: 7n addition toiseihdmg tine form to the address in 24a
2.Well construction mmethod: p 7 above,also submit Otte copy of Buis form+within 30 days of completion of well
i
1 a Well
minty,cable,detpusb,ear) _ �' uedon to the foUowhW. !
Division of Water Resources,Underground bdedlon Control Program,
FOR WATER SUPPLY LLS ONLY: 1636 Mail Service Center,Raidgb,NC 276991636
�
t
139.Yield(go m) McWcd of testr- r l 24c.ja Wa et ftft&Iniecdon Wells. In addition to sending the fame to
•—Lj the address(es)above, aim submit one copy of this form within 30 days of
13b.Disinfection type± Amount: completion of well construction to the county health depa meat of the county
where constructed.
Farm(iW-1 North Carolina Dap ntneat afEuvkommntd Qa ty•Division of Water itesmaces ReYW 2-22-2016