GW1--03329_Well Construction - GW1_20240603

WELL CONSTRUCTION RECORD W-1 Print Form
For Internal Use On�` __
1.Well Contractor Information:
David L. Hardy, Jr. -, -
Well Contractor Name
t4.WATER ZONES
OM TO DESCRIPTION.
2. ,
NC Wen Contactor Certification Number R ,...7
� �
Aqua Drill, Inc.
Is.OUTER CASING(for muW.c walls OR LINER
MOS ro me..., .
Cotapaay Name -- /.ilii c ,�A a�
lm f i �f 2.Well Construction Permit#: r.2� I Ci I-,FROMCASING OR TUBING .r,
Ltrtall applicable well connruu/an its TO tt �; In. RtL=
permits Re WC County.State,Yanmrce,etc) ft. MATERML
3.Well Use(check well use):
R • in.
Wafer Supply Well: n SCREEN --
-
Agricultural °MunicipaUPublic FROM DIAagIEa. tt[tIT
0 R Rt in. �— 1ffitS MATERIAL
a Geothermal(Heating/Cooling Supply) °Residential Water Supply(single)
Industrial/Commercial }Residential Water Supply(shared) ft.Ill
;r Int I.;on
is.GROAT _
Non.Water Supply Weit: RUN—
MATMUALoD&
MINT
Monitoring R' Q 1
Injection Well: a'Recovery ft. 2t /� f1�O�s yie"' O�I�
)11 Aquifer Recharge °Groundwater Remediation 8 IL
-a -.uifer Storage and Recovery - ()Salinity Barrier �.S41 GRAVEL PACK(if sPP8ahleli
al. °SAquifer FROM TO MATERIAL — EMPLACEMENT1nETROD
tonnvater Drainage B ft
Experimental Technology °Subsidence Control —
*Geothermal(Closed Loop) OTiaeer 20.
Geothermal(Healing/Cooli Return) DRQ.LpYGI,OG(aimdeed�floyDs>eeralP
Other(ex.lainttnder#21Remadrs) PROM TO 1° �4ae►meta sFeae�)
4 Date Well(s)ComptetedJy sZ t 4 �� r4 , e✓
1 ell ID#
Se.Well Location: ��- ���e%� •
ei -%sad !�
Facility/Owner Nnme Fealty fDk(if applicable) ft t g C /42.41,L `
e, e i l/ 4 A X/G%,l 4,C/. ft.P sisal Address,City,and Zip
ft. R.
21.REMARKSCounty Parcel identification No.(PIN)
Sb Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweil id,one lat./tong is sufficient)
/2/m7( O, - 9-N Wea
6.Is(are)the well(s)0Permanent or C3Temporacy Signature ofCenified Wait / 2
r
e
7.Is a repair to 00 existing Yes or By signing this form,1 hereby c the wells)war(Were)constructed In accoodaoee
If this thisi r repair not brown wall well:l:ecrlon 1 ONO with 1SA NCAC 02C.0100 or 1 C 02C'.0200 Well Construction Standards and that a
repair under 421 remarks section or on the bock of far otn and erploin the neuxrr of the ropy of fhb record liar bean provldead to oho will"Wei.-
repair
23.Site diagram
a.For Geoproloe/DPT or Closed-Loop Geothermal Wells having the same You ay use the or additional
of this well details:
construction,only 1 GW i is needed. Indicate TOTALconstruction details. You ��to provide additional
nal pages
well site details or well
drilled: NUMBER of�ells may also attach additional pages if necessary.
9.Total well depth ` SUBMITTAL.IN_-_ UCTIONS
below land surface: (a)
For multiple wells i O aidepOu fidigerens(exampl 3e 3@200' 2 100 24a.$or+ Walla Submit this form within 30
® 7
construction to the following: days of completion of well
10.Static water level below top of sating; �/,�
I10. tie!is chore casing,use"+^ ( ) Division of Water Resources,
Processing Unit.
11.Borehole diameter. ( )
1617 Mail Service Center,Information
27699-17
246.Forjniection Wells: In addition to raiding the form to the address in 24a
12.Well construction method: l/' / 7� ' above,also submit one copy of this torn within 30
(in.auger,rotary,cable,direct posh,etc.) construction to the fallowing days of completion of well
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
l� 16361Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) -�--f-___Method of tesh�
�- 24e For Water Supply&Igieetion Weljg In addition to sending the form to
DisYnlection type n Amount the address(es) above, also submit one.copy of this form within 30 days of�1111 _ completion of well construction to the county health department of the county
where constructed.
t North Catalina De
partment of Environmental Quality-Division of Water Resources
Revised 242.2016