GW1--01589_Well Construction - GW1_20240308

WELL(CONSTRUCT1t N'R to3 D(6W-1). . . .For Internal Use.Only: '
1.Well Contractor Information:.
, ..... .17. , .
•
Ch1is•King: • 14,WATERZONES • .
Well ContmctorNaole • FROM. TO DESCRIPTION_.. . •
208o-A -:V/o ft• '1 1 ;. 1 . G.f1:�P,:l
fr . .tt.•. .
• NC WeII'Contmctor Certification Number •
: :15.OUTER CASING:(for meld-cased wells)OR LINER(If ap-licable) -
Aqua Drill,,Inc. : FROM•- •To . . DIAMETER . THICKNESS . MATERIAL.
Company Name • '.R• '�"/a fC /�y in:: -J Dii 2.I.:� ��_ , t `
•.16.INNER CASING OR TUBING(geothermal dosed=loop).
•.2.Well Construction Permit#:Q5(Jrl P-2o23 -. 460( . • FROM '• TO, DIAMETER • . THICKNESS. . MATERIAL .
List all applicable well const nctionpermits(I.e.-UK Comity.Slate..i'irrinnce,we.) ' • . • ft• ' ' EL In..
3.Well,Use(check well use):' • R. • -ft. . In,
Water Supply Well:. 17.SCREEN
.FROM TO. ' - DIAMETER .SLOT SIZE THICKNESS .MATERIAL _
Agricultural. Munici al/Public '
p fr.: n. in.
o .
Gcothernral(Hcating/Cooling Supply). 1jcsidcntial Water Supply(single) H, it..-
. in. -.
Industrial/Commercial • . DR,csidential Water Supply(shared) 18..GROUT•
IRigalien . FROM. TO . MATERIAL• _ _EMPLACEMENT:METHOD&AMOUNT -
Non-W,iter Supply.Well: ' "_ • " ft.• '. ft. "�'� 1 A v.
Moniforin=. 0" �� :I3CM1�•t'lot•IC V�,. 5 . .
b .ORecovcry . . ft.. .it:
Injection Well:
Aquifer Recharge GrouridwaterRemediation. .
Aquifer Storage and Recovery ID:salinity Barrier SAND/GRAVEL PACK(tf applicable)
•
!:� ty . • FROM' . "TO MATERIAL F.11P1:ACP.4IENTl1rETHOD
Aquifer,TestStorinwatcr Drainage: tt:. ft..
Expenmental.Technologyy QSubsidence.Contra! ft. ft.
Geotht..mu.l.(Closed Loop)' .DTracer• •" . 20.DRILLING LOG(attach additional sheets if necessary) .
Geothcrmiil(i ieating/Cooling Return) I�iiOther(explain under#21 Remarks): FRU�t I To. • IMCRlPTtIoN(color,buaacss aolurotk tope;grain Ku,etc.)• .-
• 4.•Date•Well(s)Completed 20.- :C WelllD# n• R•:
it 1dS Swi+Je:G:-. ItoGt
Sa.Well Location:. ' '?OSft.' 5-6. ft. 13 Itre '• 6izA,u,..J e .
C�4 cr, • n •
T onave,it ite� . •
ft., • • . ••ft.' , .
Facilit Owi...Name ft•' 'ft
Y 'Facility IUq(if applicable)'• ' 4 �„•,
4
2'O 3 .5 Ptri Aig sI;ene: •ILA: s 44 u,J):c•0,C ft• ft. .. -("a € V. c . . .
Physical Address,City,and ip. ft. •.ft. •
-
Lt 2L13EMARKS rr�w Zn7d
County. Paiccl Identification No.:PITS • - ?rr •A
• Sb.Latitude.and longitude in degrees/minutes/seconds or decimal degrees:_ •
. _(+fir. 3
(if well.field,one lst/long is sufficient) 22.Certificatl
. •N• W /^�
.6.Is(are).a.wcll(s ermanent .or " Tenr or • Date
Ce .2O i�
cr, p •Signature of Well Contractor, a-'
81•signing thix.jnm.I hereby cert/i ihiii the Well(.a)war(acre)constructed in accordance
• •.7.Is this sr.repLir to an existing well:' "'lakes -or,41,Rio • trilli ISA NCrIC 0K•00100 or 15.4.NCAC 02C::0200 Well Cnndrncilru,Standards and theta.
ff1/iis 2+•rr'repel,;.fill mit kno+in well ronstradtun hifrrmurimr m+d-etplah+the ironrre a/n w i:a)m"rf lhde+era rl I,ae beanpmrldedio the lixl.o,,nen.
.repair ender r.21 remark section or an:the b• uck r f thie.limn.
. 23.Site diagram or additional well details:: •
-
.8:For Geaprobe/DPT or Closed-Loop Geothermal Wells Saving the same You may use the back of this page to provide additional.wall•site details or well
constructiiul:only.1•GW-1 is•needed: Indicate TOTAL NUMBER of wells' construction details.-You may also attach additional-pages if necessary.
'drilled:. . - . -SUB,'VITTAL INSTRUCTIONS
9.Totalssell depth.below land.surface: _-J. OO .. .' •- (ft.) •Y4a:.For,Alf Wells; Sabmit this-form within-30'days-of.compleion.of well
•
For'nwliiplc wells list all depths(fdilferent(example-3tw200'and_tin/001' -construction to the following: 1
10.Stave water level below top Of-eating: •( :O . . .(ft.) Division of Water Resources,Information-Processing Unit,
Iftrotcr level is above casing,use +' -- 1617 Mall Service Center,Raleigh,NC 27699-1617.
II.Borehole diameter: 4. (in.) -24b:For Infection•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.Weil canstruetion method: .1a"1 IZ' 1L.1 1 construction to ng:the-the
(i.e:auger,rotary.cable;direct push.etc.) -
Division,of:Water Resources,Underground Injection Control Program,•
FOR WA a Ls2 SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a. 'iehi(gpra) . • 1: Method of test:_ 5 1 l:/I T'. : .24c..For•Water-Sunply&:ioiectloi Wells:•In-addition to sending the form to
'1 • '•the'address(es)•above,.also submit one copy.of this form•within 30-deys•of
13b.Dislufectiatt.'_yne:, i 1 J- . . Amount:")L Q' . "completion of well construction.to the:county.health department of the county
Where constructed.,-
FormGW-t- :North Carolina Department cif Epvironmenlal Quality..Divisionof Water i2
Resonates- Revised -22-2016.