GW1--01596_Well Construction - GW1_20240308

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8VELL.CONStRUCTION.RECO r;:r.(GIA&11) FOr Intemallise OnlY:- -
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.1.Well Omitractof Information:
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Chris King 14.WATER ZONES- : . _. . - • ' . . .
- •FROM- •• TO-- • .DESCRIPTION - ' ' ' . .
Well Connecter Narita- . -
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2680A. .. .
• ft.-. . ft.- [ . • .: -. .
" : •NC Well.Contractor Certification Number
'IS.OUTER CASING(for ainIti-easedivefts):OR-LINER(if air limbic) • -
AQUB'brill,:Inc. FROM.: - - .TO .: .1 DIAMETER .. THICKNFSS- . MATERIAL, . . • .
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- • • - .-If). t.t.-. 70 ft.. ..6fici,L.I.... ,5 0,1,7 i. ,..-.(21 td,.. .,.. •.. ..
Company Name
•16,INNER-CASING OR TUBING(geotbermal-closed400p) • .. . ... • . .
A i /1 OPt . •FROM• . "TO ' -DIAMETER- - THICKNESS. MATERIAL .
'2:Well Construction-Permit#:• • • _i 1 ‘..•-• i • . ..
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List all apPlicohle well constrwriion permits(1.e.VI(:County.State.Variance.ete.) •
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ft. • In; . . . .
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I.Well Use(check well itae)t . . .
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. . .Watet•Supply Welk.
Agricultural - -)111Munie-ipal/POrblic
Geothermal(Hcating/Coolmg Supply):/Ai;•esidentiril Water Supply(Sinale)'-..
indUstrial/Conimercial: lateaidential•Water SUpplY(shared) : - IFF178RR.:S:C:R.I.::::NT:T6:0 .
- Irrightfon • .".'ft..-,'.....•DIAMETER' sun siza ._ititainss- .MATERIAL
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. . MATERIAL : EMPLACEMENT MpffO &'A3t3NT.
Non-Waiter Supply Well: '0-.IL-...i3O'. . .1.3'eA4r0- . f4c. •61-1415. .-- '.5'-c • • .
Monitoring.. .. . . Recovery' .. .. :ft.• . ' :ft..
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Injection.Well: , '
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AquiferRecharge- -pGroandwater Retnediation. . . • - : .
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19.SAND/GRAVEL PACK(If malleable) . .- • . . • - _ .
Aquifer Storage and Recovery- ip Salinity Barrier -FROM - -TO' - 'MATERIAL ' . . 'EMPLACEMENT METHOD • -.. ..
Aquifer Test OSteriniArateiDrairiage- ft.- . •ft.. ' . .
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•' Big:edit:cut&Technology' :E3Sitbsicience Control ft ft • •. • .
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.:- Geotherima(Closed LoOp)* DTracer- •20:DRILLING LOG(attach additiOnal sheets If necessary:). - - - '
•FROM • ..TO. . . DF-SCRIPTION(color,hardness,soil/rock type,grain size,de.) • .
4Geothermal(Heitirtg/Cooling'Return) .17110ther(explain under 021.Reniarlis).. : . -
-7 ./.1!) ..), . _.. ..
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-4.Dite•Wcil(s).Completed: —,-.2-",2 - - Well ID# . .1,...../
. •.. 6. .!.'! 6.5"'• '' Stud• ..it0C IC
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.5a.WeillLocation: . ..61St'.. 76.51'- Bite' &stop•i4C . . •
":-. .._\\ .7.7VOr . . . . -. ft. ft.' : .
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Facility-0 N:une " . ''FacilitylD#(if applicable). ft .ft
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•'• . ft.: : t.,-4 1!‘"-.i '' • ;. P 1 -v.-,.-,„,, .•
c?. 1<-..1:4,f., .pki.1),-p:5_ pd: Bedifuot.;,01 id : . ft.,. -, : . ..- a f .__ !.
:ft. - ft. : --- .4.1; V 1......d..1
Physical Address,City,and ZiP-
(..• 141 . - -
..: -4h6A• m _ . . .•.21.REMARKS ' . ' - -' .
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MA Ft 0.s 1074- ,T
County ,Parcel Identification No.(PIN)
. . :- • iliac..';eria*VC:a i-)FT..4...N7svel
_ .Sli:Latifude.and longitude In.degrces/minutesfseconds,Or decimal degrees:. -. .- '. . .. . . - , - PAPIC"::::::;
(if well field:owlet/long is sufficient)'- '22..Certificali n:
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Signs um of Certified Well Contract ,-" Date
•6.Is(aire)the wells 1W,P crmanent or Temporary
.Brsigri/ag this Arlo,I iterehi cern/i that Me wall(s)seas(were)"cmistnwied hi accordtinee•
7.Is thiki a repai-to an existing well:- -OYes- o" No ror/ Oh.aft A'Ciff,02.0;0100 or.I54 NCAC.02C:.0200.Well Construdion Standen&and that a
'If this'li ttreptdr.fill nut knoini well cemsintrilowhihrmailon um emiltihitlie IIIIIIIIT tithe copyedit?Mtlird liar been Provided to the well.miller; .
repair ant'lerial-remarks swarm or on the hack tithlslann: .
23.-Sitc diagram or additional welidetalls:: . .
a.For Geoprobc/DPT of Closed Loop Geothermal Walla having the Same You may use the.back of this page to provide additional Well site details or well
constnict:cso.only I 01,71-is needed..Indieate:TOTAL NUMBER cif Wells• construction:details:You may also:attach additional pages-if necessary.
-drilled:
SUBMITTAL INSTRUCTIONS
7d-C
9.TotaliVel!depth below land suffice: -. - - . -(0,) 24a.For All'Wells:• Submit this:form within 30 days of coinPletion•of well
For multhile welisitst all depths idliferent(example,3(0200'and 20:100)• .construction to the following: ;
10.-Static water level below-top-of casing: .to 0 - (ft) Divialonof-Water Resources,InforznatiOn ProcessingVnit,
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If sassier level hi it/wren:sing use 1617•Mall•Serviec Center,-Raleigh;IN 276994617
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:11.-Brirehole diameter: ‘ . CI' .. • (In.) 24b;For Inieedon Wells:.in addition to.sending the font to.the address in 240
m 1. above..also submit• one Copy of this form within 30.days of completion of well•
12.Well construction method:. Pr IL el.TZt:).)- - - constructicin-to the following:-
(i.c..-augell rotary,cable,direct push;etc.)
- - - - Division of Water Resources,iindergeoundinjettion ContiolfrOgram,.
FOR WATER.glinLY ELLS ONLY: 1636 Mail Service center,Raleigh,NC-27699-1636
132.Yie3d(gpni) ..V . Method'of test: 7"B I 9 n-t- . : .24c.For Water Snooty.&Inlection-Willst- In:addition:to sending the:fonn:to -
the address(es) above, also submit one copy of this form within-30 days of
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. 13h.Disinfection type:• /4771 . :Amount ) a-.. e) .6., . . . ',completion of well construction to the county health.department of the•county-
- •where conatructcd. 1
Fenn Ow-i North Carolina Department of Environmental Quality-Division of Water Resources: Revised 2-22-2016