GW1--01888_Well Construction - GW1_20240322

*ELL CONSTRUCTION RIECO o'l• (GW-1)• • •.For Internal Use.Only:.
• . 1..Well Contractor Information: .I '
• • . lls King: • , ..Ch 14.WATER ZONES I '
WdlConlractotNome FROM. TO . • • .DESCRIPTION._ • . '
2080-A- . 169•;_I66. f."_ co .aiii N' . ..
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NC Well Contractor Certification Number : :15.OUTER CASING'{for multi-cased wells)OR LINER(If ap Stable) " •
a Driil,. •'Aqua. iliic.- FROM• TO-- DIAMETER . .THICKNESS MATERIAL
Company trarric • •• .©. fG .�2Iti :6://1S•:!o: )'0 :�:6ici t✓ . .
ssj •�, _ p •/ • -• 16.INNER CASING OR TUBING{Qeothermal closed-loop).
.2,Well Construction Permit#:k7 1 3. 4...4•�L �3:'I • . FROM - TO. DIAMETER • " THICKNESS. . MATERIAL
List all applicable null consln'rclonpermits(l.e.'U/C'County.State..Variance,'etc.) R. : it; In.:
•3.Well Use(check well use):- tt.' fL in.
Water Supply Well: 17.SCREEN .' - .
• • FROM' •TO. • DIAMETER -SLOT SIZE-. THICKNESS MATERIAL' •
• Agricultural. QMunicipal/Public ft.: •tt. :In..
• Geothermal(Hcating/Cooling"Supply):2kcsidential'Water Supply(Single). ft.: _ n:. .tn.
Industrial/Commercial - Residential Water Sup'plyi(shared) 18.GROUT
Irrigation . . . •• FROM ' TO . '. .MATERIAL. EMPLACEMENTMETHOD&AMOUNT• •
Non-Water Supply.Well: • . - -° . .,v ft!• Q • R: 66 4e
Monitoring.. .DRccovciy :- - R.: �• 1�,"�
. Injection Well:.
Aquifer Recharge 0Groundwater Remediation.. . ' • ' • --• . . • . • .. .• • • .
Aquifer Storn and Recovery. Salini Barrier 19:SAND/GRAVEL PACK(If applicable)' - ,
q- . O, ty . • -FROM :TO. . .MATERIAL.. • . ! ..F•MPLACE:11E1T METHOD .
Aquifer.Teat QStormwater•Drainage: : it. •
Experimental:Technology • Subsidence Control ' 11: fir
Geothermal,(Closeil Loop). .QTracer . . . . I0.DRILLING LOG(attach additional sheets',necessary) • .
"Geothermal(Heating/Cooling Return) (Tt Other(explain under#21 Remarks)' : •FROM • TO. HT ek
•DFSCRIO'(color,hardness,soil/ro type;web,size,etc.)• .
ft.:.3. n. Sal:
•4.'Date•Well(s)Completed:3' -A 7-1. Well lD# n• rt '
5a:Well Lat itien: 15'— it.'. 4'1l5 it31u 1:' xigti�C
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•
ft, . .fL
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•Facility/Owrw tirime• 'Facility ID#(ifappllcabic) tt., tt.
IOC 5otl4-iit'2n1 :)4%IA: 5i."466:j: •lad - ir. : it. • . •
Physical Address,City,and Zip- •ll fL - ft,• r( r—'5\/o r—
/)li'9m•AKl(C' • LV • •21.REMARKS f sa 4« 0. s a.a ..
t
County. : :Parcel ldentitication'No.:(PIN) . hi b D C) 7 707d. . . . - :
5b:Latitude.and longitude in degrees/minutes/seconds or decimal degrees:- . - •
.(ifwellfield."onelat/long Issufcient): ,' . . '22.7Certife• on: IrtfO u..c.c^^.i)i SCy'. ?,5 t3Y'
DVQrvi
. >d. . W
6.Is(are)the wells) ci'matient •or..DTemporary. • Signature ofC tificd Wall Contincto Data •
Bt'signhtg II&Ce fain,I hereby ierlj':thal the well(i)read(were)canoinuted in accordance
.7.Is this a.repezr to en existitig'well: 'Dyes or i ce"so , iritlrl54•NCIC 0'C,0100 or 15A NCAC(1'C.:0200 Hell Consnyteilna Standarite and 0iat'a.
If tliis is a rip:dr.Jill ma karma well construction b frrrnai nri and etplaln the hat*tithe caltr'gilu to in ur d has:been prui•1Jcd to the Well owner.
repair under i 21 remarks section or milhc hack of lhisroan. : . . . •
• 23.site diagram or additional well details:.
. 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You tray use the Back of this page to provide additional well site details or well
construction:.only.I OW-I is-needed: Indicate TOTAL NUMBER of wells' construction details.•You may also attach additional pages if necessary.:
drilled:.
G •SUBMITTA.L INSTRUCTIONS • .
.9.Tote!Well depth'below land.surface: t 3' .� , -'lit) ; 24a:.For:Ail Wells: :Submit this;form•within.30 days of.complction of well•
For'multiple wells list ul/depths Pigment texaniplc-30 00'and 2(w1U0) :Construction to the following: -
10:Static water level below top of casing: 3 0-: . . . . , . . .(ft,) Division of Water Resources,Information-Processing Unit,
jtmter level ie ahem rasing,nzc`"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (Q (hi.)'
24b:For Iniecdon.Wells: Tri addition'to sending the form to the address•in 24a.
•
' " " i above.:also submit one:co of this.form witliin:30
.12:Weii•constructlon.method: A 1-.F. •um; / l' . . days of completion of well
(i.e.auger,.rotarj•,cable,.direct push,etc.)
construction tithe-following:.
Division,of Water Resources,,Underground Injection Control Program,. • '
•FOR'WATER.SUPPLY WELLS ONLY: - .1636 Mail Service Center;.Raleigh,NC 27699;1636 •
Oa!eld(OW 50
. 1
(P,p-) 7 Method of testa 7 i , f I 74c.For-Water Supph•&io n'.We lectiolls:•In addition to sending the form to
f.• (. • •the•addrcss(cs)"above,.also submit one copy of this form'within..30 days•of
13b;Dislm oetien ype:.Ii•Ti .Amount:./•( •0•� completion,of well construction.to the:county health department of the county
. Wher'e consttiteted..
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,Fount GW-i • ;North Carolina Department of Environmental Quality-Division of WaterResources' • Revised 2-22-2016.
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