GW1--03686_Well Construction - GW1_20240618

WELL CONSTRUCTION RECORD(GW 11 [For Print Form
Internal Use Only:
1.Well Contractor Information:
David L. Hardy, Jr. `
Well Comaetor Name 14.WATER ZONES
FROM I To I DESCRWflON
2906-A 11 7e. 7S p/:y L/c/-, /l fhb
NC Well Contractor Certification Number R
Aqua Drill, Inc. 15.OUTER CASING(for muld.on wen )R LINER eta amble)
FROM I TO D1AME'rER _ Tm s MA
Company Name �ft• ft. + !m' •Dt ' G l ei
Z Well Construction Permit#: / i a� 'f' _ 2 16.INNER OR 1 (motbermdmedaoop)
I
i to eft applicable sell construction permits(Le WC,Cow* SJ PROM 70 DtAMEfER THICKNESS MATERIAL Stale,Variance,etc) R ft. ft,
3.Well Use(check well use): ft. �
Water Supply Well: 17.SCREEN --
Agricultural DMunic;pallPublic FROM TO DIAMEIU stalrsus Tmtwy.ss mounts i.
Geothermal R �.(Heating/Cooling Supply} esidential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) 18 GROUT
Irrigation
_Non-Water Supply Supply Well: Him aJl�T —' cn� }�gO/y�AmpmerMonitoring
Recovery ei Se f'16•l tr t r I �'71:1 ti„l/// /i, 7f
Injection Well: ft. ft.
Aquifer Recharge OGroandwater Remediation ft. f
Aquifer Storage and Recovery ?Salinity Battier 19.SAND/GRAVEL PACK fitapplicable)
Aquifer Test FROM TO MATERIAL — EMPLACEMENT 3EHM
DStonmtater Drainage ft. R
Experimental Technology DSubsidenee Control ft. • RI
Geothermal(Closed Loop) °Tracer
Geothermal �.DRILLING LOG(attach adetltioral sheets if mrrr.ry)
•
(Healing/Cooling ng/Cooling/R'Return) Other(explain under#21 Remarks) PROM D> tioN corm;tura�, yr ,Sofa,�
4.Date Well(s)Completed: S�3/ $ Q u i
coal@/! R /C/I S4,idtele
Sa.Well Location: //
t.
e .J lam' / re(,., ; 71 e-
FecilitylOwear Name
Milf y� Facility lIN1(if applicable) y ft. R. —
7,J / , 4 1'/o/i le,i,'/I %U^ L tk./tin l-r, /�/C ft. f. ; i
P icai Address.City,and ! a e ` • 11 r 1
nd
County r f 21.REMARICS _ .IL Pf .1 ta )1V4 .
Panel identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ir,EZ:X4'm F�� r'^r r "
(if well feld.one lat/longissufficient) .1�� Utilik
3.2 iL ZEZ6 N,,g / 17 4 22.certi6eehon:
cl ! it W thi/71?6.I5(ere)the well(s) Permnnent or !�T Porary em Si ofCerti eel Well C
7.Is Phis a re By signing this form,l here et*that the uell(s)war Ow.wryib
pair to an existing well: ?Yes or,,E3No with 154 NCAC 02C.0100 or 15A NCAC 02C.11200 Well C arneenionee
If this it a nspa/r,fill out known weft constr.:salon Information and explain the notate of the copy of tills record hot been provided to the well owner. oarnalkaanilkeliamif that a
repair under 421 remor/ascction or on the back ofthisfonn,
23.Site 8.ForGeoprobe/DPT or Closed-LoopGeot6ge You maydus the back of this additionalram or coal details:
construction,only 1 OW i is needed. Indicate TOTAL NUMBER of wells same pagetot attach
additional
onaitpage i fn site details or well
drilled. construction details. You may also attach additional pages if necessary_
9.Total well depth below land surface: �m �j SUHMI I-IAL INSTRUCTIONS
rmutgplelld Walldepths ndiferent(example-30200• 100� (ft) 24a.F9r All Wells for
Submit this m within 30 days of completion of well
wellconstruction to the following:
0.Static water level below top of easing: C) �
Ifwater level Ls above wring use^+^ ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1"' DM)
JJ 24b.For Infection Wells: In addition to tending the form to the address in 24a
12.Well construction method: A ,,( /4-i above,also submit one copy of this form within 30 days of completion of well
(ia auger mtsry,cables direct peak eta) construction to the following:
IFOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpnm) I Method of test: ,•yJ1/ 24e.For Water Slowly&Infection WelJls in addition to sending the form to
\Disinfection type: !�7 ���/d Amount: the addresses) above, also submit one copy of this fort within 30 days of •
Or completion of well construction to the county health department of the county
where constructed.
%l North Carolina D Quality-j Department of Environmental usliDivision of Water Resources Revised 2-22-ZO16