GW1--04111_Well Construction - GW1_20240712

WELL CONSTRUCTION RECORD (GW-I) For internal Use Only: !
I.Well Contractor Information:
Chris King
14,WATER ZONES
Well Contractor Name FROM I TO DESCRIPTION
2080-A ft. R.
II. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licablel
Aqua Drill, Inc. FROM TO DIAMETER cJ/IC THICKNESS MATERIAL
MATERIAL
Company Name O EL
R. l 9 (/q in. J IZ 2/ I I 'ii r C
Cr ) ) 16.INNER CASING OR TUBING(geothermal elosed-loop)
2.Well Construction Permit#: (� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e VIC County.Slate. Variance.etc.) ft. ft. in. •
3.Well Use(check well use): ft. fI. n.
Water Supply Well: 17.SCREEN
❑ cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
- DMunicipal/Public rt. ft. in,
Q(icothcrmal(Heating:Cooling Supply) Residential Water Supply(single)
ft. D. in,
industnal.Commercial DResidcntial Water Supply(shared) I
18.GROUT
IrTigenon FROM TO MATERAAI- EMPLACEMENT METHOD&ASIOCNT
Non-Water Supply Well: /'� II. �/q R' ��,,M /_ C,t1 t��Monitoring �Rccovcry �'l ft.
D`U ft.
7C
injection Well:
Aquifer Recharge 0' ft.
q DGroundwater Remediation
Aquifer Storage and Recovery Salim Barrier 19,SAND/GRAVEL PACK(if applicable)
h' FROM TO M.4TF.RIA1. EMPI.ACF.�fF,N7 METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft,
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if neeessan)
Geothermal(l leatinarC'ooling Return 1 ;Other(explain under H21 Remarks) FROM ro DFr 'SCRIPT n?',color,nartlncss,saiVmck type,grain size,etc.)
(/w / Q ft. 2C ft. ,z C C! C l A y
4.Date Well(s)Completed:Y1. - 02CWell ID# R. A Q D- 5,i,d� o
I
Sa.Well Location: aO ft' Qs 4� ?t. J3 kJ C ���TTTIA�i \i C
ft. V R,
Facility Owl:::Name Facility IDe(if applicable) ft. ft. t-.,. f
a. D.
Physical Address.City,and Zip ft. ft. 2O['t
•[--e K e 5 1 21.REMARKS
I1R:+:I-A.;, ''
County Parcel identification Nn (PIN) ; -y
5b-Latitude and longitude in degrees/minutes/seconds or decimal degrees: '
tifwell(kid,one Iai long is sufficient) 22.Certification:
N ri eV /� 6
1�—.2 `ISi arure oiZcltt;l-9 Vcll Contractor pate6.Is(are)Inc wel(s)— ermanent or QTenpornry
By signing this/in'ta./hereby midi,that the udll(c)tux(uxret committedin accordance
7-Is this a repr.L.to an existing well: QYes or igrZo with 15A RCAC 02C 0100 or 15.4 NC4C u2C 0200 Well Construction Standards and that a
!Phis is a repair,IIIl ant known well e,war lrtiwn inhumation and c vpIain the na/+o'r of Me (opt'of this record hay heco)prodded to the+yell orcacr
repair under a?l remarks section or an the hack of this form
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
constnlctiu^.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple:cells list all depths if(Vern,(example-34200'and 2ta,IOW)
Cl 0 construction to the following:
10.Static water level below top of casing: b (ft) Division of Water Resources,Information Processing Unit,
If water leer!is nha re,using,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: (4:7 `'/n� (In.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
IL Weil et nazi etion method: I� I i' iZ ` � ) above, also submit one copy of this form within 30 days of completion of well
(i.e.auger.rotary.cable,direct push.etc.1 I 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.1'!eId(g(srn) 3 Method of test: �'' 1 h f 24c.For Water Supply&Injection Wells: In addition to sending the form to
J� 7► 1 the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection!Tye: ! /pe: ) Amount: 3(1 0 ` completion of well construction to the county health department of the county
where constructed.
Fang GVI-: North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-21116