GW1--03052_Well Construction - GW1_20240520

vviru,)L, tUIVSIRUCTION RECORD (GW-1) For Internal Use Only
6.7-
1.Well Contractor Information:
Chris King
14.WATER ZONES
Well Contractor Name FROM TO
DESCRIPTION
2080-A ��,,�,o fL ;a ) ft' 6-1 P.r►-)
NC'Well Contractor Certification Number ft. ft.
Aqua Drill, or 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM TO DIAMETER I THICKNESS MATERIAL
Company Name �� ft. ft. 16)AL in. SOit
1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 1 FROM TO
List till applicable ce/i c•ouctrnrtirm permits(Le. VIC•.Coatis.Slate. Variance.etc l ft. DI:\J1 F.TEk—, THICKNESS MATERIAL
ft. in.
3.Weil Use(check well use): U. I
ft. in.
Water Supply Well: 17.SCREEN —
AICUItuTa1 FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OMunicipal/Public ft. ft. in.
Gcothennal(Heating Cooling Supply) rs.sidcntial Water Su pl
I I Y(single) ft. ft. in.
Industrial•Conmurcial DResidential Water Supply(shared)
Irri;atTon 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Monitoring QRceovery ft' 0 ft' 1 t�roTe e h;t'J
r
Injection Well: fl, fj( n {V F
Aquifer Recharge O(iroundwater Remediation ft. ft.
Aquifer Storage and Recovery OSalinity Hamer 19.SAND/GRAVEL PACK(if applica)Q
FROM TO MATERL\1_ EMPLACEMENT METHOD
Aquifer Test OStonnwater Drainage ft. ft.
Lxperi Men tal Technology 0Subcidencc Control
_ ft. ft.
Geothem:al(Closed Loop) Tracer _
20.DRILLING LOG(attach additional sheets if necessary)
Gcothern.al(Heating/Cooling Return) 1-7::Other(explain under i#21 Remarks) FROM Ti) v....c PTfpN(color,hartlnexs,soil/nick hpc,>pin size,etc.)
O ft. (0 ft. c/ C 1 A ,
4.Date Well(s)Completed:5-)3` ` Well ID# 1
ft. i -7�, ft. S A)vd 12Uc X
5a.Well Location: 1 7Q ft. '1 fJ�c�t `
)�p.t// 0 6 W e r1 CS ft. ft.
Ili l>J C� 12/4rV,'T�
Facility( v:;,r Name Facility IDS(it-applicable) ..`ft. ft.
n/ .21 T l7 )2 Re l 511 ii 1 e C
fN/ a 1 ,,3
ft, ft
Physical Address.City.;;tad Zip
—
.
C r)c c.,e)1 21.REMARKS
County — q
Parcel Identilication No.(PIN)
5b.Latiturie and longitude in degrees/minutes/seconds or decimal degrees: I
(dwell lied.one tat lung is sufficient)
22.Certification:
NW ../.....2S_
6.Is(are)the well(s) ermanent or OTemporary Signature of Certified Wdl Conti ctor ��
Date
7.Is this a fCp£] t0 an CxlSting well: Dyes or Br signing this Jana.l hereby rertifp ilia,the well(s)was(were;constructed in accordance
atNo
If this is a,pair,llrt am knun•n,cell erm.ci/nc lion in/in•umrnn and erploin the nature alai, copy r f Ili /ry o hashe l,rprov d d in the well m n0200et Well Communion Standards and shut a
repair aadc•r:c?/remarks section in on the hark of tins/bn,,.
S.Fur Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagramusathe back of thr is l page
to pro
1lls`d additional well site details or well
eonstn(ct.o only I OW-I is needed. Indicate TOTAL NUMBER ollvells You may
drilled: _ construction details. You may also attaat additional pages if necessary.
9.Total well depth below land surface: a 6 S- SUBMITTAL INSTRUCTIONS
For multiple wells I/.ct all depths if Jt//c.renr n•.runy,/c-31,c2)O unit'vr/!1!1') (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.rStar!(cew,atehnle\(el beloww easing, `top of casing:
(ft.) Division of Water Resources,Information Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Weil cunstrucrion method:�� f �Z , f above, also submit one copy of this form within 30 days of completion of well
(i.c.au�cr.rular ,cairlc,duce,push,etc..) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR'\'a:c;Ell SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.`:'!eld(:pm)
Method of test: i 24c. For Water Supply& Injection Wells: In addition to sending the form to
13b.Disinaetiaa tve^: [��f / he addless(es) above, also submit one copy of this form within 30 days of
! Amount: )/� � � completion of well construction to the county health department of the county
where constructed.
Fonn Gu. i
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016