GW1--03197_Well Construction - GW1_20240524

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only:
1.Well Contractor Information:
Chris King
Well Contractor Name 14,WATER ZONES
FRONT TO DESCRIPTION
2080-A 20 sit. 26i(c H. 0 G P
NC Well Contractor Certification Number ft. n,
Aqua Drill, Inc. IS.OUTER CASING(for multi-eased wens OR LINER No licablel
FROM TO Dr.Ax1ErEtt THICKNESS
MATERIAL
Company Name ..) It. 165
of 5— n. O �y in. Spa
16.INNERIN CASING OR TURING(geothermal closed-�p) �,t
2.Well Construction Permit#• �40 FROM TO List all applicable well construction permits(i.e.WC.Caton..State. Variance.etc.) ft. DIAMETER_ THICKNESS MATERIAL
ft. in.
3.Well Use(check well use): ft
ft. in.
Water Supply Well: 17.SCREEN —
°Agriculturai °✓Municipal/Public FROM TO DLAMET n SLOT SIZE I THICKNESS MATERIAL
°Geothermal(Hcatin Cft. ft. in.
g` oolin g Supply) �ftesidrntial Water Supply(single) I
°Industrral.Comnloreial ft R. in.
Residential Water Supply(shared) I 1
n[Irigi ion 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL_ EMPLACEMENT METHOD&ABIOBNT
�Moniton°g �Recovcry 0 II. d fL l iv-IlVlit C 11 �)j
Injection Well: II. ft.
°Aquifer Recharge °Groundwater Remediation ft. ft.
°Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
. FROM TO MATERIAI. EMPLACEMENT METHOD
.,
Aquifer.est °Stormwatrr Drainage
°Subsidence Control
I ft. ft.
Technology —
ft. ft.Geothenra!(Closed Loop)rm °Tracer
20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) —';Other(explain under 021 Remarks) ,FRoal ft. TU DF7SCRII'T10N<obr,6a does.salUrock Qpearain sire,etc.)4.Date Well(s)Completed: J -2 1 -2`{Well ID# I ft. CS: fL 1Ze S�J1/� C�
Sa.Well Location: � 5 Ito
CJS ft. cod 5- ft j3lu e '"1Ztgp.41 C
ft. ft.
Facility(hirer Name Facility IDd(if applicable) ft.
R.
i37� Noc�P"efz LZC4 I')'�1CbSind C j� ,(, ft. ' ft.
Physical.Address.City,and Zip ft. ft.
CWS(�C j ) 21.REMARIGS —
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Of well field.one latlong is sufficient)
22.Certification:
N
NV el,v2,
6.Is(are)Me well(s) maneot or °Temporary Sig
By Certified WcU Co,nracmr' / ' /
Date
Bt signing 7.Is this a reps: to an existing well: °Yes or Olo with/3A 1•C.4C/02C.01t0D in-/5.4 NC-IC 0hui 2C 020(Je r/H'e//Construction um ftroroi Standa in rdd,f and that a
(Taus is a,repair./li/ma known sell nursnta rinn infrn•ntaswnr and etyilaia the nature nit/re a"'ref this retard has heea prrn•lded in the nr/1 nu nm-
repair under n21 remarks Seal inn nr an the hock girth,.Jima.
23.Site diagram or additional well details:
R.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
construction details. You may also atta
consintetiu..only I GW-I is needed. Indicate TOTAL NUMBER of wells c.ir additional pages if necessary.
drilled.
ti O SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
For multiple!,;its•list all depths i/<lljfercar(example-3raMO'and2 a-iUhl') (ft.) 24a. For All Wells: Submit this foam within 30 days of completion of well
CO construction to the following:
10.Static water level below top of casing:_
Ifurtter level is above rasing,use-+" (ft.) Division of Water Resources,Information Processing Unit,
G 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
�f 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 11 IZ drti above,also submit one copy of this form within 30 days of completion of well
0.e.auger.Miry.cable,direct push.etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.l'eld tnprn) f O Method of test: `�h-'� 24c.For Water Supply& Injection Wells: In addition to sending the form to
D�r/f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection'ype: ` Amount: (g completion of well construction to the county health depamnent of the county
where constructed.
Form CL\'_; North Carolina Department of Environmental Quality-Division of Water Resources Revised 3-32-30 16