GW1--01318_Well Construction - GW1_20240229

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•WELL CONSTRUCTION.RECORD(GW-1)- .. TOT Internal USe Only:' • .
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. . :1.:Well Contractor Information: . .. .
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. .Chris'King .. . . .
. . . . .-. .14.WATER ZONES - ": • . : • . . • .
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Well Canimetor Narne• . . FROM '. TO . . DESCRIPTION• - • . .
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20.80,4 ...,7/0.ft,....31 i. '.ft.,. Jo..,e,„ )?i..ri•, . •• • .
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. . ..,Well 00*115Cir CcrrifiCatio4 Number - ' •
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- •I&OUTER CASING(for Multi-eased wells)OR LINER(if applicable) • : •-• . . :Aqua-Drill; Inc. : - : . - . FROM TO • .• • DIAMETER THICKNESS• . • 'MATERIAL
. .Company Name•
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- - 0 ft.• •612ft., •4•'n ..in.-•.. t sv.... -4Aiii. . • • • -.• ,
. 16.INNER CASING OR TUBING(geotherinal closed-loop). . - • . .•
. - •2.Well ConstrrictiOn'Permit St $7."1.I..ab.C.)(-;to• FROM . TO . - .. DIAMETER THICKNESS' • MATERIAL
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' • .List all applicable well construction permfts(i.e.-clic ulloi,co .State:Variance.ete) ft. ft ID .
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• '3.Well Use(check Well use) - - .
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Water Suy Well:.
FROM. ' TO . - .• •DIAMETER- •SLOT SIZE• THICKNFaS• 'MATERIAL' • .
• Agricultural • • .: DMunicipal/Public • it.' . ft.• •
' Geothermal(Heating/Cooling Supply)", Residential Water Supply(single) • . ft. . . ' :ft.: • to.
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Induatrial/COmmercia1. . QResidential Water Supply(shared).• IS GROUT" '. . .. • ' . _ . .. ... . . , .
Irrigation .• . . • . ' FROM. '. TO • • • MATERIAL . EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well
• :- •.. . • ' ' . . .: . •a -ft; .245:ft...._ i3eaiii40 d.iii 9: .-5..- .C_ . : ..
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Monitoring •DRecoVety. . - . rt. .- - : ' .
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:Injection Well: . . .
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Aquifer Reeharge ' . 1:1CiroundwatcrRetncdiation • . ." . • .
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• 19.SAND/GRAVEL PACKlif applicuble)- , ' : . ' : • . . . -
Aquifer Sthrageond Recovery • .:Osaliiiity,Barrier " FROM - To• .. •MATERIAL' - •-. EMPLACEMENT METHOD
'Aquifer Test 0 Stormwater Drainage• " • 'ft.. .'ft.
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Experimental Technology :0Sitbsidence Control • ft. ft
•. . .. Geothermal(Closed Loop) • ' Tracer . ' .. . . 20.DRILLING LOG(attach addltIonid sheets if necessary) -. -.:
FROm( . ' • 10. • .. • •DESCRLPTION(cotur.hardness;sallfrotk line;Mtn size.etc.)
. . . Geothermal(Heating/Cooling Return):. :flOther(explain under in i Remarks))
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4:Date:Well(s)Complcted - - • Well ID# . • : • : - : 3.. ,f!.. : .)5.- .ft. s A rud. )z to.C..K. ..:• : . .. . • ..:
•Sa.•Well Location: • . 1 ST' .ft'.-.3.251-1.• -O.)6' . 67-ilt1 i'lj1.:1 e!: . .,'•• . '. '• .
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Facility/Owner Name • - - 'facility ID#(if applicable), . : . . .
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.57576 5 'NO /.... • 9q• 136 a 1.';.rj 4'16/.0' NI C •
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Physical Arldress;Ciry,and Zip • . . It ft
; 211 REMARKS - FF-
Ml a 9. 6.-ln.,: ..... .1-j. ..• -. .-iIiiiVee... • . • .
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County . . . - .- • -Parcel IdentificatiOnlia.(PIN). • : - „. - • - • - ,...-,• ' - : •- • • ' ' • •
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,•51):Latitude and longitude in degrees/minutei/Seconds or decimal degreeS:, . ' .'. . .. ' I
(ifwell.field,one 1st/long is sufficient) -
• 22..Certification:- • - ' :0963
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'6.Is(are)the Well(a)6Dermatient or.f3Temporary.". . 'Signature of Certified Well Contractor , - 'Date
. .By signing ilia fern, I hereby certify(ha:tife.wd/N:wai(Irene)Constructed in accordance
7.Is this a repair to an existing well: • E3Ves- or.(610 with ISA.NCACO2C.:0100 or ISA‘NC4C.02C:040 Well Construction Standards and 1/join ''.1fthis era reliair,•fill and knottyz tie construction information and&plain the stature of the ' .rcoPy of this record hOsbeinprOvided to The well on net
.repair under#21 remarks section or on the back Of this form.,
23;Site diagnini.oeadditional'well details:. • -• - • - . •
8.For Geoprobe/DPT oiClosed-Loop'Geotherimil Wells having the same You may Use the back of this page to.provide additional well site details or well
construction;only.1 PW-1 is needed.'Indicate TOTAL:Numata.'of wells • construction details.:You may also attach additional pages if necessary,
. .drilled: .• • '. - .. •
• c.,__.• . - SUBMITTAL1NSTRUCTIONS ' . .
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:9.Total well depth below land surface: • .:' .4:.3: - . - (N..'24a.'For-All Wells: -Submit-this form-within•30 dad of completion of.well
Far muldide.wells list all depths lfdloireiu(example,.2@200 and 2@agol .
. construction to the following:.
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10,Static water level below top of Casing:. - 6 0. -' _ . - . - (ft.)' .Diviiion or Water Resources,InforMadort Processing Unit,
. . If linter level is above casing,we"+" •
. 1617 Mail ServieeCenter,Raleigh;NC 276994617". -
.11;Borehole diameter:' •6 . (in.) .
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. •24b,FOr infection Wells::In'addition.to.sending the form to the adcfress:in 24a
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12.Well.construction method:. A•42 -.-di4.-1-1. •
. . . . .aboVe,also submit' one copy of this'farm within 30 days of completion of well% ,
construction to the following:
(i.e unger,soterseable,direcrpush,ete.)-, -
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• ' " . - " • • , , -Division of Water Resources,Underground Injection Control Program,.
. FOR WATER SUPPLY WELLS ONLY:- .1636 Mail'Service Center,Raleigh,NC 27699-1636
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13ri:Yield(gpm) ) 0: Method' of test:.'5.4 gig 4- . . •24e.for Water Supply Be InleationI.Wells i In addition to:sending the form to'•
the.address(es) above, alacrsUbmiti one copy of this'form within 30 days of• .
13b.Disinfection type: 4 ria• .• . Amount': :).6 .6:Z. . . . .completion of well.construction to the county health.department of the county
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Form OW-I - - North Carolina Department of Environmental Quality-Division of Water Resources • 'Revised 2-22-2016