GW1--01581_Well Construction - GW1_20240308

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-WItI.L.tONSVIRUCTIONROCORD:(GW4) . For Internal Me•Only:. , . .. . .......T. . . .
'I.Well:Contractor'Information:
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Chris:King . . . . .14.WATER ZONES: • • _ I •
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•FROM. ' TO' DESCRIPTION .. . .
2680A
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Well COntractor Name
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joy .ft. .J0,17 , .-.s- oi 0 8 pi- . .
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rib. f.i'. IR/_ -•'.- /a 6/ ati - - - . . -.. . • .
.•NC Well Contractor Certification Number •
IS.OUTER CASING(for multi-cased we0lls)OR LINER Blau liciable)• - : .
Aqua.Drill,'Inc. • FROM. TO . . • 'DIAMETER', . %THICKNESS ' MATERIAL
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tompaniNgmc • • ". '0' ft-.-' 1.6....-ft. 62 q. ht...5DA.2-1 - ..‘nt 1-IC .- : .
' 16.INNER CASING OR TUBING(geothermal closed-loop)'. . .
.2:Well Construction Permit ii:.A:7:Cri$:0. T. • . . . . •. •FROM -.- TO . . . DIAMETER 1 ' 'THICKNESS MATERIAL • .
'List till applicable well consintefion permlte(i.e.UIC.(omo..State:.Variance;eta) .h.- ft.: . In.
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ft. ' '
.1.Well Uselcheek well use): 'ft... in. .! •. _ .
Water Siipply Well •
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17.SCREEN' . • . • ' l' _ : : . . : .: • • :• FROM. TO ., •DIAMETER. SLOT SIZE •THICKNESS MATERIAL
Agricultural .DMunicipal/Publie- . .
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. . .Geothermal(Heating/Cooling Supply).-,Ekesidential Water Supply(single) - : • .ff. .. -. ft.: . . - In;. -. • . . . . • . .
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• industrial/commcreial .DResidential.Water Supply(shored)' •
' •.. krigatien• . . . . . . . . . • 18.GROUT
FROM - • TO -.- MATERIAL,:.• EMPLACEMENT METRO 10 . . . . .
.. Non-WMerSuPply.Well: .0.. fi.' '20' ft. -13wilkii.4e•_ .d.)1 •135 . •-.S.-C
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• igonitiiitig.. DRccovcry . . ..
. . .. .- Injection Well:- • . • .
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Arpiifdr•Reeharge :1:3Groundweter ReMediatiOn . . • . . ' . . . . . .
19:SAND/GRAVEL PACK(if applicable)' ._ .. . . . . . .
" • - Aquifer Storage and Recovery -Dalinity Barrier FROM - TO. -- MATERIAL •EMPLACESIENT METHOD
Aquifer Test .OStormivaterDraimige • ft.
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Experimental Technology . .0 ttbsiderice.Control
•. Geothermal(Closed Loop). •DTracer - . . •- - .20.DRILLING LOG(attach additional sheets If necessary). .'.FROM DESCRIPTIO
' • ' ,-TO • ' , N'Oblot,hardness:soil/rock type i,gran uset
,cc.).
•i Geothermal aleating/CoolingReturn) '117()ther(explain tnder.#21 Remarks). • . . . . . . •
.'0 . ft'• 2• -ft. ' )Z.Cei• '.d tpii .....,. • .. .. .. .
4.Date Well(s)Completed:2' '/.7......e CI Well um . . .. • 3 ..ft."6.0. ".'. )31..)e -di Ay, --.ni u d-•
Sic-Well:Location: . 6.0•.ft.. .ft.. .)1,11ici:
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- SO: -ft-• .2251.*:..- 1;1 ucl 6pAAJi4e ••
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FaciiitytaWncr Ikinine • • :Facility ID#(leapplicable). . . .. . , . .
tz u-y .y . ft.- . -ft.- : . ' p7-7.:-..7.---1
.ft.• • ft: ! 1 k.,.„..s_,L i v PhysicalAddress.City;and Zip.
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• • 21.REMARKS* • .
R0(-4 PXj - • .. . - - • • M,-VN i'li O• 2024 . -
County Panel IdeatiticMion No.(PIN) . '
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tritorraatir.n
•Sb.Latitude and longitude in degreedininutes/Seconds or decimal degrees; ' - '. •• - '' . . ' . .
LANO.i aoG
(if well field:one let/long is.sofficient) 22;Certificadim:
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.- natureOfOo .
6.Is(cre)tile Well(i)OPermisnent. .or E3TeMPOrary % rtified WeliCntr74 • Date
1k:doing ihli Ann,1 hereby eeriai.dun the Well(e).was(were)cansInwied,in acciwdance
7.Is fits 1.1 repelr to an existing Well:: :Dyes- or eli:Nis:. . scith ISA NOW 02C.6100.ar i SA.NCAC.0.2C.0200 Mil Cansirudian Mandel*and that a
If this ix.a rpalr,fill an;harm)well eansiructimi inlinftibnfamlitiplain the nature edit, eapy nf ibis record has been pi-elided lo theittill owner.
repair smiler r;21!meths.ceelion or on the hark.lihis.finm..1'
23.Site diagram or-additional well details;
S.'For•Geoprobe/DPI or Chised-LooiGeotlierMillW.eils having the same You may,use the back of this.page to.provide additional well site details or well'
construction.only I-GW4 is needed.Indicate TOTAL NUMBER of wells- -construction-details.-You may also.attach additional.pages if necessary.
drilled:.' . . .
. . 'SUBMITTAL-INSTRUCTIONS-
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9,Total Well depth land surface ' ,:.A.-.4.t..): . . . - - - (ft.) 24a. For All Wells ',Submit'this form•within 30'clays•of completion of well
-Forma/if,*wells listundepthi ifdikerent(example.30200'imd 201001 construction to the following:
10.State water leiel.below top-of casing: -_5--- . IN Division Of WaterResources,InfOrmathin Processing Unit,
. Ifiswer leiel I S(ibotie casink.use."+7 1617 Mall Service Center;Raleigh;NC Z7699-1617
IL Borehole diameter:. .- 6. •(in.) .24b.:For infection Wells: In addition,to sending the-form-to the address in 24a
' 12:Well ecasiracrion Method:•_.g.;12...., . 'CI.it's •I' I. above,also submit.one copy of this form within 30 days of completion-of well
construction to the f011owing: !
(i.e.auger.irotary;cable:direct ptisli..etc.).
Division-of Water Resources,Underground Injection Control:Program,
:FOR WATER SUPPLY WELLS ONLY:: 1636 Mail Service Center,Raleigh,NC-276094636.
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13a..Yicld(gpm). ').5-- . . Method Of.test: 59 irt .24c.For-Water Suably al InkietionlWells:-.In addition to-sending the form' to-
.the eddress(es)-above, also- Submit one-copy of-this lorm within 30.days of:
. 13b.Disimbetlest:ype:- /-4.-..T 14 . . •Amount:. )g.0 Z . . completion of well.construction to the county health.department of the county
where construCtel ]
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources. 1 'Revised 2-22-2016