GW1--02495_Well Construction - GW1_20240422

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WELL CONSTRUCTION:RECOR]) Gov•1 _ _.
•For Internal Use Only: ; , ' ' •
I.Well Contractor Information:
Chris king. .•
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Well Contractor Name 14:WATER•2ONES
FROM . •' TO .
DESCRIPTION ••
2080 A :,39w#•. 39 l i: .: S ( p
NC Well Contractor Certification Number • .R•
Aqua.Drill, InC: . iS:OUTER CASING'(for multi-cased wells)OR LINER Ran lieable)'• •'FROM TO' DIAMETER 'THICKNESS. -MATERIAL..Company Name ft I' ln,-
2.Well Consereetlon"Permit#:"3 I I•V 16.INNER CASING OR TUBING(geothermal closed loop)
FROM- TO .. 'DIAMETER THICKNESS •
List nil applicable'Ng urksinrcrion permits(le UK,.emint.:'Stme;i'riFiance:era) •fL•. MATERIAL.
ft: la
3.Well:Use(check well use):'
Water Supply Well: . .- . • , .
ft..' it. in
11•Agricultural - . . FROMREEN� �
,....eipaUPubli6 ' •DIAMETER SLOT SIZE THICKNESS ' MATERIAL
$Geothermal(Heatin Coolie Su l.. fr` fL in
g PP Y) BBesidential Water Supply(single)
�i Industilal/Commcrcial °Residential:Water.Supply shared) ,
hi Ira�•lion. • ,. ( _.1&GROUT � - .
ft. In.'
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Ilioni w lion Supply Welk -_ . .
'MATERIAL. EMPLACEMENTME'rHODa4AalOUN1'•
?Monitoring. . -�Nlle •
FROM•.
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® ' R , � `�
fL'
:111•Rccovcry ft -'l.•�'1 � . .
• Injection Well: • .
fL"
jiAquifer Recharg •
e R.
Grounihvater Remediation f. -
iAqurfer Storage and Recovery rjSalinity Bamer., ": 19.RAND/GRAVEL PACK(if applicable),
FROM. . TO .
...MATERIAL' ' EMPLACEMENT METHOD.
al9 Aquifer Test SIOrmwater Drainage . ft. yt,
:altExperimental Technology Subsidence Control
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,l�'Geotherima!(Closed•loop) �Trircer . - • � .. • • • • .
ft. g, .
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Geothermal(Heating%Coolin� Retnm i • • L To OG a eets If necess ry)
g ) ]Other(explain under#21 Remarks DESCRIPTION(color,dardna) �eaiVrodctYae:grain elm.eta):�
20 DRIL (attach additional
f6
OM' DFS
4.Date f7Vel!(s)Completed:"I_ 'i • I. Warn, . it. to AraC
Si Well'LocaBon:
F►dJd'�' 5 JdS'ft ua5t, lSiu :_ �rri9/�ta:t •
ft •
Facility Owrec"lime Facility ID//(ifapplicablc) ' ft: •• {t �. .�
V7� _ o:ra: . id . 2ii , ,K- . N, :. -
Physical•Addri s:Gry,and;Zip
AS(ie-Ii • • . . •.21.REMARKS, tt.. _ �.. •..•
County •trt�t; `y' L;. ,�i:_
Parcel ldcntification No:(PIN) • • • . Ltd
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(if well field.one lat/Iongis sufficient) •
22:Certillc 'on:
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N W ,
ermanent or DTemporary Signature of Ccnified Well Contraetar
• 6.ls(src)the wdl(s '9.- I:2
• Date'
7 Is Wfs a repair to an existingwell:, Sit sigNng gas fan,, 1 hereh,:miff,dun the well(s)was(were)cnnetnicied In accordance
DYes or NO " with 154.A'CAC6?C.0100.or 15.4 NCAC 02G 0200 Hie/I Gmsirucliati Standar&and that a
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(Phis is a r..pwr,giant known,hill cipslntt(inn hlar niuiinu and mpliii,the nature Oldie Coln r ft/we,es aid lice been pros lded.to the well o,i,w,.
repair nnr/er 121 remarks section mini the hick rrf//ui fan,,
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23 Site'diagram or additional well details:
8,For,Geoprobe/DPT or Closed-Loop Geothermal Wells having the-same You may use the back of this•page to provide additional well"site:details or well
constructio,r,only 1 OW-I is needed. Indicate TOTALNLMBER of.Wells " • ' construction details. You may also attach additional pages if necessary:
drilled: -
SUBMITTAL INSTRUCTIONS "
9.Total well depth below.tand surface: '�w _ • (ft;)
For multiple wells list all depths iJ'djQeirw(exu nple-3fw300'a nd?(ailuuq 24a•-For All Wells: Submit this form within 30 days of completion of well
construction to the following; t
10:Static Beaters level below top of casing: ° _ • (it)
Ifiiatcrlevel is dhow cesbng_use"+ Division of Water Resources,Information Processtng.Unit,
1617 Mail Service Center;Raleigh,NC 27699i1617
11.Borehole diarectere (In.)
,/� , 246.For infection Wells: 'In addition to sending the'forni to-the address in 24a
12,Welt construction method: J�I R Li[ZI 1 I above,also submit one'copy of this form within 30 days of completion'of well
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(i.c.auger,roiarj•,cable,direct push,etc.) construction to the following:
FOR W,ATEf2 SUPPLY-WELLS ONLY: • Division of WaterResources,Underground Injection Control Program,
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1636 Mail Ser•vtce Center,;Raleigb,NC 27699-1636
I3a.Yield(bin) SI: . Method of test:"-0•( I''1 f 24c.For Water SUDDI &infection Wells: In addition to sending the form to
13b.Elisinfection ,� N the address(es) above; also submit one'copy of this form within 30 days of
type: Amount: )6:'Ly-Zd completion of well construction to the county health department of the county
Where constructed.
Fotrr GW-i Nnii,r..,.i:....n_.-.__. - ..