GW1--02211_Well Construction - GW1_20240409

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WEYIL CONSTRUCTION RECORD:(GW1) : For Internal Use:Only:'
1.-Well-Contractor Information's 11. . .
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Chris:King • . 14 WA ERZONEs i ii.
WeII CoatractorNatne FROM . TO" . • • .DESCRIPTION I I.
•2080-A - •.3.�7 :. 37/.fG 3'Zit?: 10 . . . _ : .
.• 'ft; ft:. ' I • - .
•NC Well Contractor Certification Number . . .IS:OUTER CASING(for multi-cased*ells)OR LINER Of ap licable). .
' Aqua Drill,-Inc. • 'FROM . .= TO' - -DIAMETER 'I. .THICKNESS' MATEAUG •
Company New . .: ( 3 6rq 'I s go. -I'1•V_cC.
16.INNER CASING OR TUBING eothermalclosed-loop). _• • . .
2.Weil Construction Permit# 1 I i �• 1, . • •i FROM: TO DIAMETER 1 THICKNESS_"• MATERIAL• . :
-List all applicable well coltetn:clionper,mis(Le..(1/C:Couny State.'Varimice;etc.) . . - rt• it in'. •
•
.3.Well Use(check well use); ft.: : : :ft. : ' I hi.
Water SuppI Well: "17.SCREEN I
FROM -• ' TO.- DIAMETER :SLOT SIZE- THICKNESS- MATERIAL- .
Agrictiltuml . ' Mtmicipal/Pubiic• ' .it: : ft,.:'• In. .
Geothermal(Heating/Cooling ' .
Supply)PP Y) . idential VJatcr Supply(singic) ft. fr: in _
IndustriaVCommorcial . DRcsidentiai Water Supply(shared) •te:.GROUT '. I
Irrigation. • FROM TO-- . -MATERIAL, I -EMPLACEMENT METHOD&AMOUNT' .
Non-Water Supply Well: O :frr. 0..-ft. J3eW,p I-� t.�j JCS . .
Monitoring DRccovery. • ' ft.' ft... _ 1 _ 1 ,
injection Well:• fr: fr:
• Aquifer Recharge QGroundwater Rentediation 19.SAND/GRAVEL-PACK(if applicable)
• Aquifer-Storage and Recovery •DSalinity Barrier- .'..FROM• TO• - - MATERIAL I -. . EMPLACEMENT METHOD . • . '
•I Aquifer Test- .'DStormwater.Drainage rt• rt:'
Experimental Technology .• 0 Subsidence Control' fr: .' fr., -.
Geothermal(Closed Loop) 'Tracer - • 20.DRILLING LOG(attach additional sheets If necessary) ' . . _
Geothermal(Heating/Cooling Return)-. i0ther�(explain under#2.1 Remarks) FROM. •:'.To DFscatr rtoN(color,n.raacss iotumct�qnc,grain size eta)
- ,r1 R.• •6• R:• . . •.!�i s ' . .
4.Date Well(s)Completed:•3'a2).:2 C/Well ID#_ . 'C4J rt•'' le .ft. ..sm.;d' -ii�'G f
5a:Well Location: •
: �J'� IL. .(,0.5":". 13)Li a I'.Ct-iZf1AJil C
fr,. fir I, •
•FaeilityI0vne7 Name. :Facility:IDH:(ifdpplicable) , ft' • 'ft • • .,.I - • •r -..--..-n 1.•f y r,1:". '
Physics ddttss,City:and Zip fr.. fr. . ' • ^P R e ?on
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• , -O J 00: 21.REMARKS_ "
County Parcel Identifieation No.(PIN) I of.;.t*,: P r7'57.r4F:„ U i'i •
Latitude and lon tude in:d .. •
vs
5b: gi egrees%minutes/seconds or'decimal degrees:.
(ifivell field:one latilong'is sutticient) 22.Certificationi . -
N: . _ W. �,
•6.Is(are)Thewell(s) ermanent or DTem or "Sig,aturc ofCorti tad We 1 Contra r : • Data
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. . P ary
Br:rignhlg:Ibl a fimn;,i herein•reel j,that the walks)ins•(urre)cvtnstrnu ted fa avoidance
7:Is titis'a repair to an'existing well: ,Wes. orrNo. • '• . . '• with ISA NC,IC.02C.0i00 or ISA NCACI02C.0200 Well Consiruelitin Standen/sand dint a
:If,this:is a repair,fill nun hail*well cnnatrzu i/an infarmatlnn and explain the naiure of the •capr of flue menthes hcen prorldcd at the ie,N inviter:
repair under 131 r ntarkt s e'hlon ar.on she hack of thisfann.. •
- 23.Site diagram or additional well(details: .
S:.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same You.inay use the hack of this page to provide additional.well site.details or well-
-construction:anlg 1 GW-1 is needed:.Indicate TOTAL NUMBER of wells . • •construction details..You'may aiso.attach additional pages if necessary:
• drilled: / • SUBMITTAL INSTRUCTIONS '
9:.Total Well depth below land surface:. . C! 6 •(ft•) 24a. 'or AU Wells Subntit.this form within 30 days of completion of well
-Focmultiple wells:list n/I depths f dperent(rx ntple-3i'200'atul2(ot100') - I _
construction to the following:"- i,
.10:Stat:c.water level below.top of casings •6 0• (ft.)-. .Division of Water Resources;Information Processing•Unit,,
If aides-levet Is idiom casing.use•'/+'• - • • 1617 Mall Service Center;Raleigh;NC 27699-1617 ,
ame 11.Borehole diameter: L+'
L . -(in.) 246.For.Injection Wells:•In addition to sending the form to the address in•24a
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above,Also.submit=one copy.of this form'within 30 days of completion•of well
12.Well construction-method: --/i(Z --f Z di. • • construction to the following:.
(i.e.auger,rotary,'cable,direct'push,etc.) l
' • - - • - • Division Of Water Resources,Underground Injection Control Program; •
• FOR'•WATEi SUPPLY WELLSONLY: .1636 Mail ServiceCenter,Raleigh,NC.27699.1636-
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.13a.Yield.((;pm)• .3 " - . .Method.of test: 7.•(Q'i'J. . '24c:'For Water Suppiv&•Injection Wells: In addition to sending the form to•
p� �r1 // ;the-addiess(es)•above,-.also:submit•one copy-of this,form within 30 days of
13b.Disirtrectiont)pee /7'TI) Amount I d7'.Q completion•of•.wdl construction ttilthe county health department of the county
• where constructed.'
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