GW1--02716_Well Construction - GW1_20240507

vn aj LON S•II RUCTION RE CORD(GW-1) " For internal Use Only: ' ." ; •
I.-Well Contractor Information:: : : .. - • -
hrls King . . ' . - ,•_ . -• ' ' : .
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•-- WellContmctor Name " ' :' ' ' - - . Fa WATER ZONES ..
DESCRIPTIO
' . " .- 2080-q.. :- :. ' : . . "-1 fit.: •c .J)i th'
Cs.n' 1G
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NC Well ContnietorCertification Number.• : .: " - " .. ' ' i .I
Aqua brill,.or Cer ' • ' ' : -15.OUTER CASING(for multi-cased"wells)OR LINER(If a. Ueable/"" " "-- "
FRO\1' I TO " ' DIAMETER THICKNESS
' `• 'MATERIAL
Company Nontc . : " . - fL I rt. / i1.0 I501811. . '. :'".V, .
� N:. G Lary
L7, c ..
2.Welt Construction Permit#:2 �} ^ / J " 16.INNER CASING OR TUBING(geothermal closed-loon)' . • .•" " • .-
p� "/000 tJte"V rian( " c • FROM. .TO'• - 'DIAMETER• ' .THICKNESS'': • "'MATERIAL•• ' '
List all upplicq/ile well Onstruc sin permits(l e.UIC Countt•,State-rtfriance,etcJ " it." R:
". 3:Well Use(check well use): . " -',
Water'Supply Well:: • • 17 SCREEN `:.
- Agricultural' " • ; " " f in SLOT SIZE THICKNESS ." MATTRL4 L
. �Municipal/Public - (t,- - R, io. -
Gcothetmal(Heating/Cooling Supply) .,5$esidential Water Supply(single) ft, :- .. • • • :
' Indtistnal(Connnercial -D Residential Wetcr Supply(shared)
Irrigation.. : ''.. . . _. . . . - .18.G OUT- " �:
•
it.
Non-gation )ply WeIL•'", ; - • " •-• •EMPLACEMENT METHOD&AaIOUNT: '
Monitorin cao ittt)I-
t ec• ...g .': . . -_ _.. - ..�R -very..- ' " .. . :'" 1-•�:. . °�„' .. .C�("�c.-"• ".:-, .,• • '". " ' .: - ' ""- - .
FROM TO-
•
ft.
ni tion We1L" f(.
Aquifer Recharge • Grotutdwater Remediation . •
Et. t?r
Aguifer3torage and Recovery Selinity.Ba„: " ' • • - A .-
19 SAND/GRAVEL PACK(M MATERIAL..
. • •TO "
• Aquifer Test METHOD
•FROM' MATERIAL EMPI,ACFg1�T Stotmtvater Drainage ; `• :tT.' ' . " ft.
Experimental Technology • Subsidence Control -• ; ' yp.. .. -• "
Geothermal(Closed LOOP): • : QTr'acet• " ' "20 DRILLING LOG.(itfacb additional sheets If n
- Geothetmal.(I"]cati4Coohng"Rctum) .�;1)0ther(explain tinder#2i Remarks): wont To...- DFSCRwrIoN teotor,hardness; ode
ft• .. " 4'P�itratn sae,Ma1•" - " -
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4:Date Will(s)Completed 4/` 4vG•11 Well IN,"
R t
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.sa,Well loeatione. .'.:. " . . • . f. .- • fat/c " ����rZs. .. _ ••f . _ . .. ." : " " • :: ..-FacilitylOwua:'am. - - ' FacilityIDN'(fapplicable).--" . - " ft •. '-,f:' "
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ggtA.J" t!!i'.1 � " - : . ' • '21.REMARKS- "" .
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-/ 5' L &'- r" )) - l�4" "4S1941)sho. A f: fL. -. . " _"� f Physical'Addss:;City.and Zip - . ' : .' : _ ', ". - f, -R, - ; '- " t'::_:- . - v.a e ",I
Cotuny: Parcel identification,No: Pi
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•'S6.Latitude and longitude in degrees)minuees/seconds or decimal degrees: •
(ifwdl,fida,one fat/long is sulrcicnq. .. . ' ' .. ' .. • • �
6.Is(are)"the ivell(s gc�ncnt or � Tempos Signa arc o d Wcll Co vC a :.
m Y ntmcto
Date
:I is tItls.a re;alrto an Cxistin wen: r �o By Sliming thli fi,r ii,I lierehi renhi Melilla wr)l(s)•itas'(aere)rawhicte'd In aceorddpce :'..
If:hi..G.a rcpulr fll n,,:Iow rn Welluiaiwvin� meat on and e.plain she nature i f the cap,•Of!/his rrsnril ha h , ruSA NCAC 03 ell°ar200 We'.: Co. ' .... '.' •'' ' gritlihurur-
repelrirnde,b21.r markcaes lion or on the Guck"r fthicforili.• . • • -- " P lded to the;yell owner.
. " • ' '• . "- " " : - .- . " •23:Site-diagram or additional well details; '• 8.For CcoprobeiDPT or Closed-Loop Geothermal Wells having the same. . You may"use-the back of this page to provide additional well site details or Well.
•:"
construeiior,only I GW-I is•needed."-Indicate TOTAL NUMBER'of wells . to ls.'You may also attach-additional pages if accessary,
• - drilled:.: • . . . -
" construction de'i
. - ' • •",SURMiTTAL.INSTRUCTIONS
9.�Tota1 ticll depth below lead"stirfacc:. - �� - • • -
For nnthiplr wells list al!depths jfdifTerenl(example,3(w2t10'and,d 2 u•) :(R'� 24a:For All Welis; Submit this Aim.within. 30 days.of completion of well
/��I construction to the following. -
10 Static water level below top of casing: • .'" (p—•• •" : (fb)
Ijttwrrr titre!is ohorc c l bet use + Division of Water.Resources,Information Processing Unit, -
• 1617 Mail Service Center,Raleigh,NC 27699-1617
i I.Borehole diameter:- • ' " • (in.) _
• .24b For Infection Wells:"in addition to sending the form to the address in 24a 12.Well eonstrac[ion method /�it •• �7 above,,also:submit one copy of this form within 30 days of.comp•letion of well
(i.e.nuger,rotor),cable,direct push,etc.) " . "•.- - ••-/ - ; . cbristntction to the'following; 4
FOR�'diI T1:R Si)i'PLY WELLS ONLY.: - Division of Water Resources;Underground,Injection Control Program;
•
• " . 1636 Mail Service Center;Raleigh,A'C.27699-1636. " ' "
13e.q'Iclrl(gpm) ":. Method of test: "Sii f • • •
: -
�J+'i(`" 24c.'For Water Sun h&Infection Wells: In addi•tion to sending the form to
13b.%)islntectlan type: y • )/ .the addresses) above,. also submit•one'copy.of this form within•30 days of -
• '/ " -• Amount:T(ri •C). .. . . " completion of well construction to the'county health department of the county
• . . •' ' - where constructed: I "
roria OW-i North Carolina Department ofEnvironnffinlal Quality;Divisidn of Water Resources,
1 Revised 2 2-2016