GW1--07311_Well Construction - GW1_20231109

WELL.:CONSTRUCTION RECORD(GW 1): • : .For.InternalUse Only; "
1: ma
Well Contractor Information: • ' • -• •
14G WATER ZONES I I
Well Co:tractor Name • • s ` ' ` ' : . . FROM TO-.r DESCRIPTION'
. •" ft. ft.
•
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NC Well ontiector Certification Number • _.� ... . • • ••• - . .
.15.OUTER CASING(for multi-cased wells)ORLINER Of elf"Usable)-: --,
•= Aqua Will, InC • ' FROM TO. •' ' . DIAMETER THICKNESS MITEI;IAL; •.`
Compan Name: • -- :• • : . . ' „illy 64 /mr,?/-2,,(
• • • ft,' /' �'. ' . in
•
/ • • 16.INNER CASING OR TUBI thermul'closed-loop)
2.Well Construchon"Permit#: ' I A•e L 1 .• • •• • • FROM,. • •TO DIAMETER . THICKNESS MATERIAL',,
•List all applicable well constritation perrmits(1 a,UIC,Counryt,State,Variance,etc.) : • - ft.: - " f.- .1 '' In.' ' -
: • 3:Well:firm(cheek well nse): • •• • ' . :' ft. ft.
Water n Well. • . .. ••• .. :• • 17.SCREEN,,
• • PROM • TO : DIAMETER SL
OT SIZE '_THIKNESS •. MATERIAL -DAgrc ltural icipal/Publio,'. •'.: ' : : lift.. • ' ft. •
::-i.•
Ijocothcrmai(Hcating/Coolmg Supply). : Residential•Water•Supply:(single)• . • . - . ' '
lndust-tal(Commercial ' . DRcsidential Water (shared) . 1 '8. 'ROIIT • • '
'' Illrrigat On .. . •. _ _.. • _.. • • • • '. .. . : -FROM TO --• TERiAL. . 'EMP CEMENT METHOD&AMOUNT
Non=Water Supply.Welk,. . ' O..: ft.:, e)R.• . g .
r.1 re
r3Moiii4ing '.•.. ..QRoaovery. : • it. •• ft..' ..r -
InJectio' .Well:
DAqui _r Recharge • : .Groundwater Reinediation .. . ' • ' ' :
• 19 SAND RAVEL PACKpia llcab e —
4.a r Storage and Recovery: Salmi Bamer - : 1 : -
•
.� ty . . 'FROM /G TO.. .' "MATF.RiAI )• .. EMPLACEMENT METHOD'"�.. .
. . . 0Aquif r Test •.•. • • . DStormwater Drainage • • • ey. . •
: :OEzperi ental Technology.• : • : : •••'OSubsidence Control. • : ft• ....ft.
OGeoth rival(Closed Loop) .• •... . :OTlacer : • ••: •: •. 20.DRILLING LOG(attach additional sheets If necessary) -
I FROM' TO .-_DESCRIPTION(color,hunlncss,solUrockiype,Rnln nineer etc) •
DGeoth$rmal(Heahng/Cooling Return): .Other(explain under#21 Remarks) .
•- • .. . . .
IV f// i .R *:fr, • • •• • . .
4.Date Wells)Completed Well ID#
• 2- n°. 57. . ..' s
5a.Well Locadoa: • • . . L• W0/���,
fey s�.L, � .
•
/ter ,• O He. .f efl al ngl44 6 : : 3-7..tt. .dyt•4t.: • .' : '
• Facdi /OvntName' •. • :" • Facility IDS:(if applicable).' . . '. ft.' . ft. : •• t • • . ' .
tn: 31 . ? �/iVG6'2.fir, ,v ®-• e ;. . • .
../.7+ Physical Address,City.and Zip • •✓• '• . . ft. 1 :.-
21.REMARKS • ' NOV ? 2UZ3
County '' • Parcel Identification No:(FIN). ' . • i.,„.-- .,:�^rl., i,t'r;',6. .
•
5b.Lad •le and longitudeIn degrees/minntes/seconds or decimal degrees •' : ' ' --
.(if well tic d one let/ion in sufficient) .. • ' . . . • . .. .
: 22 •Certlticatlon�
•
•
•
•
•
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' 6:Is(arei the wells)y`+'Permanent :or• Tem o :Signature of Cert•ifi•ed Wall Contract Date
- _ L.
p racy
7:Is this a repair to an,existing well: . Yes.:or �o •rib A NCAC 02C 110d or 15A NCiG 011t.:03b(0 fyi11(iv
QQ������ • re):ronitnirfed In accordance
® L�'fi`.. . i Cvnslrrtcllon Standards dnd!hat u
ifiks:Is arepair,"fill out known well Construction information.and'erplain i/ie nattier of the •COP).of this.record has been provided tv the well own.er.•'' '
'repair and r#i21 remark's sectloa.or on the back of thisforiu, .
23.Site diagram or additional well details:
8:For G' probe/DPT or Closed-Loop Geothermal-Wells having the same• • .Yon.may.use the back of this page to provide additional well site details or well :.- "
• .. constrict on,only.l GW-1-is needed:-Indicate TOTAL NUMBER of wells c may also attach additional pages if necessary•
drilled:.. cons
truction details..You
�5,
SUBMITTAL INSTRUCTIO
9:Total elf depth belowaand surface: (fG)'. • •-
1r 24a.Air:All Wells Submit.this`form within 30•days.of•completion•of well For inithip e.wells ILO al!depths(fd(geretit(example-gopo.arid 441 p) construction to the followin r
•
- :la.Stab water_level below top,of casing:. 1 - (ft.) Division of Water Resources,Information,Processing'Unit,
Ijwater le rl Ls above rasing,use '+ 1617 Mall.Service Center,Raleigh,NC 27699-1617
11.Bore ale diaiiieter:. • _ . • .
f S ecOPY f dig form$within 30 or of com etion of w ll •
•24b Far Infection Wells:
above,also submit on
12.Well onstruction Method: .. co. !� P
(i.e.au er;rotary; : • construction to the following.. • t '
� tary,cable,directpush,'etc.)� � i • •
• Division of Water Resources,Uiidergronnd•Tnlection Control Program,-
FOR WATER SUPPLY:WELL$ONLYb • • 1636 Mail Service Center,Raleigh,NC 2769-1636
• /+ • • J I I
• 13a,Yield(gpm). - . ] : • • .Method of te_st:. !1T.. . . • 24c.For Water Supply&Infection Wells In addition to sending the form to
7 ' l.,/ the'address(es),above, also submit:.one•copy of this:form'within'30 days of •
13b:Disi ifection type: • . / • •. Amount: (G /O . I'
completion-'of well construction to,the.county:health department of the'county
w erePonsiruotee:• i
Form OW-I! North'Corolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 .