GW1--06684_Well Construction - GW1_20231017

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER'ZONES, . ; 1 =i,- _
Well Contractor Name FROM TO DESCRIPTION
2080-A /co ft. jelled,
Li ft. S` 6,1't ti.
ft. ft.., I '
NC Well Contractor Certification Number
15.OUTER.CASING(for multi=cased,wells)OR LiNER(if•'ap lieable)-
Aqua Drill, Inc. FROM TO DIAMETER" THICKNESS MATERIAL
C. a. 30 ft. 6, lq in. 10 raz) l / Vr,C,
Company Name
�1 '16.INNER,CASING OR TUBING'(geotfiermal closed-loop): ,
• 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State,Variance,etc.) ft, ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN• . :;
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Oesidential Watcr Supply(single) ft. ft. in. _
Industrial/Commercial DResidential Water Supply(shared) -,
PP Y "'18.'GROUT. - - - . - ,
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: CCU ft. ,J 6 ft. j?C�, J -C. C 11 i f•Si
Monitoring DRecovery ft. ft. 1J
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation
39.-SAND/GRAVELVACK(if applicable). . ' • •
Aquifer Storage and Recovery (Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD)
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Cloos,ed Loop) Tracer '•,20.-DRILLINGLOG-(attach.additional.sheets if necessary) • -
Geotherme4(l-Teating/Cooling Return) Other(explain under#21 Remarks) FROM TO D�fESCRiPTION(color,har�/dness saiUrock h pc,grain stu etc.)
rf 0 ft. / R' bait (,I J1
4.Date'Well(s)Completed �.25'43 Well ID# lJ ft. Is-- ft. Aif 1 ��G
ic
5a.Well
11 Location: is ft.ft. p2 ffrft. 6 j o t thz4 hi)At_
Vl c,LO .- C cZn( !D
Facility/Owneril Name Facility IDS(if applicable) • ft. ft. F^...:.4-.,,.f 'i••_ re-,.'.
f 1r ,p J I ���l. ,�
��iq l�)l {$f�Ill �-C ft. ft. 1 .
Y
Physical Address,City,and Zip • ft. ft. •
OCT` L / 1U1i
SkoreS :21.REMARKS . .' - ,.....:.. :_ -•- .
County Parcel Identification No.(PIN) D. „_,0;_
5b.Latitude and longitude in degrees/minutes/seconds-or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N WgeZ6-1—
V / ' 9 ^,2s -
6.Is(are)the well(s)0Permanent - or IOTemporary Signature of CertifiedWelTContrac r Date
By signing this form,I hereby cert(h'that the wells)was(were)constructed in accordance
•
7.Is this a repair to an existing well: DYes or15o with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well constrrie11on information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: . ---.2. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a?00'and 2@100') construction to the following: ;
10.Static water level below topof casing:g: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (Ca (in,) 1
24b.For Iniection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 4/ 2 C 1t 111 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield(gpm) Method of test: Sigg f-- 24c.For Water Supply&Iniection Wells: In addition to sending the form to
l/ 1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: /� Amount:1 .7.. completion of well construction to the county health department of the county
where constructed.
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