GW1--00913_Well Construction - GW1_20240209

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WELL CONSTRUCTION'RECORD-(GW=1)' , For Internal Use Only: ' .. .
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1.Well Contractor.Information: -
-Chris King ' . . ., 14:WATER ZONES ' •
Well COnlraCtorNa111C • FROM TO DFSCRI . ON • . .
2oso=a 2?p1r. .71 ".• id itr t in • . •• '
ft. : ft: i
. .NC Well Connactor.Ccrtification Number
1S.OUTER CASING(for multl-cased wells)OR LINER(If op noble)
Aqua Drill; Inc: • FROM .TO - DIAMETER '. • .THICKNESS MATERIAL
• • • • • ' tl: % iu . .
CompanyNume'. 0 ft.... ffittc .A;A/// .
16.INNER CASING OR TUBING'(geotbermal closed-loopy
:2'.well Construction Permit#SS 33L,J r 11J•Z FROM: .TO . DIAMETER` • .THICKNESS MATERIAL .
. List all applicable well construction'permits(i.e:•UIC,Connry'State..'Variance.etc). •H- . • '1 .
3:Well Use.(check well use):. • • f1-' 1L. . 'In.
• Water,Supply Well: . . • I7.SCREEN
FROM TO .DIAMETER. SLOT SIZE THICKNESS• .MATERIAL. •
• . .•DAgricultural' . :0Municipal/Putilic f� H in.
QGeothermal.(Heating/Cooling Supply).. sidetitial Water Supply(single) ' ' -R,' . '- ft:. - in. ••
',DIndustrial/Commercial Residential.Water Supply(shared). - 18.GROUT •
I itigation• . '. FROM • 'TO '• MATERIAL • .EMPLACEMENT METHOD&AAMOUNT '•
Nan-Water Supply Well:: tL: ft: 1 �.
. O 2 o Ba�j,ul Chi
0Moiitoring . ' •' • . ' . 0Recovery. " '. - ft.' ft. •
• Injection Well::
!Minter Rech' ' . .
� _ ®Grotmdwatcr Rcmediation' . . . '.- . . . . .
19.SAND/GRAVEL PACK(If rapplicable)
Aquifer Storage'and Recovery; ' :[3Salinity Batrier : FROM: .7 .
: -MATERIAL' . ' EMPLACEMENT METHOD
Aquifer Test �Stormwater Drainage -fL . , R. _ .
Experimental Technology' OSubsidenee Control n." '' ft.
Geothermal(Closed loop).' QTraccr 20.DRILLING LOG(attach additional sheets I necessary)' ' • - ' - - . ' "': . '
Geothermal(Hearin Conlin Return): FROM. ' TO . DESCRIPTION(color,hard.Bea.soWroektlpe,grain Ore eta).
(Heating/CoolingOther(explain under.#21_Remarks):
4.Date Well(s)Completed:. )• .23•^2• ell WD#" W
6 C• R: .:YS .fL' Slime .JZd cif '.
Sa.Well Location: J ft• So'$$ ..�3'�[!C .(�1Zaut4e.. .
. R,. .' D.
Facility/Owner Name ' Facility.IDS(if applicable)- it. ft. ' •
2 aq l T dj�. /,. a R: • n:. . . .
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Physical Address,City;end Zip. fL ft•
> l f J I/ -.` .
21.RMRKS91>�a� q>�c� . . .Count),;. • " Parcel Identification No.(PIN) . - • ! FFR- e Q 202g .
51i.Latitude and longitude an'degrees/minutes/seconds'or decitnal'degrees:. ' ' ' ' ` • - " - -
- _(if well field,ono 1st/long is sufficient) :22.Certification:• r 1 3,tr 3 J/`%
. : . N W _
l 2S.2.Y
6:Is(are) Signature of Corti 1 d'W
the wells) rnu a
nent .or:: Temporary. ccto . :i Date
By;signing this form,.I hereby certify drailhe nall(s).woes.(were)constructed-In accordance
7:Is this a repair to an existing well:: :[3Yes :or 1No:• . w'ith NCACISA 100 or ISA NCAC 02C:0200 Well Constracilon Standards and that a
if/his is a repair Jtl/onl knonai well construction information and explain nature of the copy alibis record has been provided to the nee/Towner..
repair lender 021 remarks section or on the back Of this faun.• :23.Site diagram,or addiN.onal well:detnilso-
• •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 1 GW-1 is needed.'.Indicate TOTAL NUMBER of wells. `.construction details..You may also attach additional,pages if necessary:
drilled: •
rr, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft.): 241i. For:All Wells: :Submit this form'within 30 days of.cbmpletion of well:
For multiple w'ells.11st all depths if dperent(e.sample-_3@200'aind 2(41l00)" construction to the following:
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10.:Static water level below:top of casing: •: r+ • . (ft.), :Division of Water Resources;Information Processing Unit,
. .If water level is above casing,nose"+'•' ' ' ,1617 Mall Service,Center;Raleigh,NC 27699-1617
11.Borehole diameter: '.�. • ON -- '24b..For:InlectIon Wells; In additicn to sending The form to the address in 24a'
12.Well construetloli method: 1}. •
(!R1•J --above,also submit tone:copy.of this form-within'30 days.of completion'of well.
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. .(i.e.auger,rory ta .cabte;directpush,etc.)• construction to.the•following:
.-Division of Water Resources,UndergroundInJeeton Control•Program, •
FOR WATER SUPPLY WELLS ONLY:. 1636 Mall.Servlce Center,Raleigh,NC 27699-1636 •
13a;'Yield(pm) 1 V. . .Method'of test'SIT. / )i T . 24c..lFor Water Supply&Iniectio I Wells "In addition to sending'the'form to • '
I • ..the.addresses) above, also:submit.jone'copy•of this.form within 30:days of
• ' 13b..D•
isinfection type: •.Amount: Id 8 Z.. .completion-of well construction to the county health department of the:county'
. ruc where constted. '
.. Form GW-1 - North Carolina Department of Environmental Quality'-Division of Water Resources. Revised 2 22-2016