GW1-2022-06593_Well Construction - GW1_20220711

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WELL CONSTRUCTION RECORD(GW-1) For Intertial Use Only-
I.Well contractor Information:
Chris King
Well Contractor Name FROM TO DESCRWTION
OIL
NC Well Contractor Certification Number
Aqua Drill, Inc. DIAMETER! THICKNESS
Company Name I !- I
List oil applicable wall construction pemits(i.e.UIC,Countn Slata Varla=4 etc.) ft.
_Well_Use�-_-.~.~~.
f!�r f, in.
Water Supply Well! ''17.'SCREEN
I- Agricultural E]Municipal/Public ft. fit. in.,
:.IGeothermal(HeatinglCooling Supply) 1-- esidential Water Supply(Single)
31ndustdal/Commercial DResidential Water Supply(shared)
Irrigation
Aquifer Storage and Recovery OSalinity Barrier 19.S /GRAVEL2ACK(if applicable),
FROM TO MATERUL EMPLACEMENTMETHOD
Aquifer Test oStormwater Drainage fL
Experimental Technology oSubsidence Control ft.
LOG(attach additional sheets-if nece
FROM TO UESCRIPTION(color,hardness,sollfrocktype�grain size,etc.)
- Geothermal(Heating/Cooling Return) FtOther(explain under#21 Remarks) & gcd y
Sa.Well Location:
Facility/Owner Name Facility ED#(if applicable) IL
C-&-ty Parcel Identificatioa No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: RAVT Q-911'rintA
6.Is(are)the weU(sek-r-anent or OTemporary Signature of Certified Well Ccrnu—=-to­r-T Date
By signing this for_,I her*cetVj5,thai the well(s)was 6vere)constructed in accordance
7.Is this arepair to an existingwell: 0Yes or 5 with 15A NCAC 02C.0100 or ISA AICAC102C.0200 Well Construction Standards and that a
If this is a repairfill out known well construction informada)i dexp F are copy of this record has been provided to the well ownei
repair under#21 renr4rhs section or on the back ofthlyform.'4229ts'aintienat ofthe
23.Site diagram or additional well hetails:
8.For Geoprobe/DPT 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 0,S (ft) 24a.For All Wells: bubmit mis romi within 30 days of completion of well
For mulyPle weys list all dePda if diffmni(example-3@200'and 2@1001 construction to the following: i,
10.Static water level below top of casing: (ft.) Division of Water Resources;Information Processing Unit,
If water level is above casing;use"+" 1617 Mail Service Cen'te lr -1617
74b.For Iniection Wells: In additioLn to sending the form to the address in 24a
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