GW1--01200_Well Construction - GW1_20240219

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WELL CONSTRUCTION RECORD(GW-1) . • : .For Internal.Use Only. ' • '•
1.•Well Contractor:InforniatiOn: .
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•.Chris King . • ,14.WATER ZONES • •. . • - '. • I•
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•Well Contractor Name FROM. • • TO '. • 'DESCRIPTION . . . •, •.. • •
40'.ft*.0. ' ft.'.. 1.7t. . . .
2080-A •
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'NC:Well Contractor Certification Number
. •15.OUTER CASING(for multi-caged wells)OR LINER(If applicable) - .. ' .. • .
Aqua'Drill:,.Inc: . . • . . FROM TO DIAMETER . .THICKNESS' • :MAXERIAL. . . •
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Colimany Name - - 0 IL '(-/.3...ft' .6•W in'- /./3Y.T.. .6-yet/vc
,„ ,,.., . .,,,, -n. • - .16.1NNEFICASING OR TUBINGIgeothermat closed400pI . •
2.Well tonitruction Permit.#: 1...-. ./..da u•c..Jei%rti.K6,--•• - • FROM• . TO• . 'DIAMETER • THICKNESS ' MATERIAL.. .• . ' .
'LlSt all applicable well construction Pe'rinits(i,e.UIC,',Connty,State;'Parlance,etc.). ft. ft.,. in.• • . .
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it. . . ' - •. 3.Well Use(check well.use):. •. • • • " "
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' . . •17.SCREEN. _ . . . • .' •Water Stipply Well:.. • . .
. : FROM ' :TO . •DIAMETER. :SLOT SIZE: THICKNESS MATERIAL '
ElAgT16UlttlIEI. . ''laidunicipal/Publie - ' • -ft. • - 'ft.'. In.. . •
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llGeothermal(Heating/Cooling Supply)jEctesidential Water Supply(single),-- • - .R. : in.: •
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Ellndustrialtommercial-' -DResidential Water Supply(shared) 18;GROIIT - • . _ - - '. ' ' . . ,
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11 irrigation.. - . . -. - . V . V . . .. . . _ . . 'FROM . TO ' . . • 'MATERIAL' . EMPLACEMENT SIETHOD',St AMOUNT
Non Water Supply Well ' . 0-11-.30 :-itH•1.1144,11c .. ' 4i.j.25. . . • ..
.Eli Monitoring. . - DRecovery -ft.- • .ft,•
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Injection Well: V .
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DAquifcr Recharge "OGniundwatcr Rcmcdiation
• V - 19.SAND/GRAVEL PACK(If applicable) . V . , ,
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.E3A.quifer StOrage'and•Recovely. 'DSalinity Barrier. ' FROM ' TO- 'MATERIAL •EMPLACEMENT METHOD . •
'ElAquifer Test . - "DStormwater Drainage - • V . ..- '.11.• -
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DExperimental technology -.EjSubsidence Control- ' .
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•DGeothemial(Closed Loop) . larracer . • . . •20.DRILLING LOG(attach additional sheets if necessary) ' --.FROM .. - •Tct.0 . - DICRgION(co7 bardoess,soll/roek type,grain size,etc.)
•nGeothermal(Heating/CoolingReturn)
I._• -lather(explain under#21 Remarks)•
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• A Date Well(a)Completeda•712:'A. V, Well 1D#.
. . ."..• 6. ..ft:. ) e.:..:
sI ud' gocK. . . .,
.,-3.51'.- 5657' ./3/oc , ei-faA/4.1•4;•C . .•.•.
. 5a.Well Location:. . . . • .- . -.
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Facility/Ovthcr Name - •FacilitY.ID#(if applicable) • ft. .ft. . ' Alcil t'''''. ;....7. i AI/E'" 1
•ft.
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•2s/6:5-C ,1-7thAi:ra_4_‘'is..t,t.c, . i2d Ji.: il
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,Physital Address,City,ondZip . . .
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- iiirfrei. .(iit'e t" •. .:21.REMARKS . . . . ' .'.. . .a--' . • '
.pumusimp,a.. • ' ••',:`,4,1 Uric, .'
• .County . :ParcelldentifiCation Na.(PIN) . - ' - . r.v.,,,: ., . .
5b.Latitude and longitude In degrees/minutes/seconds or decimal'degrees:
(if well field,one lot/long is sufficient) V "22."Certifi tion: .
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• ' S mitare of Ce ' . ontrac Date 6.li(are);the well(satermanent- .or..DTeinporary - ;)
Well tor. . •
_,.. . . • - .By signing MA.Tann,:I hereby ceiiffy that the well(s)sins•(vvcre)constructed in accordance
7:.IS this a.repair to an- existing well • •Dyes -.0.0.00,1iNci• . - • • - is .13A NCAC 02C,0100 or NCAC 02C.0200 Well Construction Standards and that a
Oink Is a raPair.fill Dahl:own.trell consihtetion•infiirthation and'explain the nothne.ofthe. vapy alibis record has been provided tolire urn Owner;
repair.under#2I remorla section or on the back.of thlifonn.. .
. 23.Site.diagrath or additional welt details: • .
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.detaila or well
. . consttuction details.'Yon may also attach additional•pages if necessary..
constniction,only 1 GW4 is,needed. Indicate' TOTAL NUMBER of wells.
drilled:. . . SUftMITTAL INSTRUCTIONS .
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• •9:Total well below land Surface: . -c:0-57, " : (ft.). 24a. For All Wells: •Submit this form within.30 days•of'completion Of.Well
For Multiple swill list all depths if different texaMple,•3(0_200'and.2©101fl. - • construction to the follewing:-.
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. 10.•Statie water level belewftip of casing; . . 3.0 ' (ft.) D.ivision of W.ateeResourees;InforthatiOn-Protesaing•Unit,. .
-limiter level is above casing ure."+7 • -1617 Mail Service Center,.11aleigh,•NC 276994617.-
11;Borehole:diaineter:. :6. . • (bn.) .. . • • 24b.-Far lnleetind•Wells:.-in additiOn.:to.sending the form to the'eddies§in 24a
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above;also submit one•copy of thisi form within 30,days..of cOmpletion of well. .
.12.Well construC ,,,tion•Method:- //I ii7-• Jai.;..,1.(- • . . . • construction tothe following:
(i.e.'auger,nitaryicable,-direet push,etc.) i ,
. • . . V :' 'Divfaithi°Mater Resources,Underground Injection Control Program,
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FOR WATER SUPPLY WELLS ONLY:. •1636 Mail:Service Center,Raleigh,NC 27699-1636
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.130:Yield(gpth)-j-1/7.- . . . 'Method of test: 5.19.11.1- .• .24e.For Water Snooty&Infection Wells: in.addition to.sendirig the form to.
*the.address(es).above, also:submit;one copy of this:form Within.30'days.of
136.-Disinfection tYpef./ 7-7--). ' •• ,',Amountii6 oz.. : •completion of well:construction to the county health department of the county
. .• . . where constructed.. '
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.-:-- Form GW,1 - North Carolina Department of Environmental Quality-Division of Water Resources - ..Revised 2..22-2016.
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