GW1--07313_Well Construction - GW1_20231109

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••.-'-a:ra!vV1IU l•1\V1.11V1l jtICil.Vnl1-(17i/V-1.) • • .For.Internal Use Only;' •
1.Well Contractor Information:
Chris King : 14.WATERZONEs' : . ,.! .I •.._. -
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Well Contractor Name - -- - - •FROM ' TO DESCRIPTION ' .
• ' 2080= • --_ •: :s 9� , ' 2 tit h .
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NC Well ,ontrector Certification Number
�J.J, • .15.OUTER CASING(for multi-cased wells)GRLINER(if ap likable)Aqua. rill, Inc. • -FROM-' ' . TO- _ •DIAMETER THICKNESS - .•MATERIAL
Com an ame • o�( 6.;,,-4)a . -...-. • •
/i /6 • 16.INNER CASING OR TUBING(two-thermal closed:loop)_ -. ''
' • 2.Well Construction Permit#:3 / t�ICiV -� FROM • •TO • .. ' DIAMETER'. •' .THICKNESS... -MATERIAL
List all applicable well construction permits(i.e.UIC,Counq,,State,Variance,ate.)
3.Well.Use(check well use): ft. tE.: , ra_ ' .
:.Water Supply Well: - . .. . • - • • .. • • .. _ .17.SCREEN -
FROM TO' ?: DIAMETER :SLOT SIZE• THICKN LESS.. MATERIA -
Agiicu tural OMVlunicipal/Public 1. ' ft. 'it In.,"' •
t �1
:• Gcotheitnal.(Hcating/Cooling Supply) csidential Water Supply(single). •--- - .
ft. . . ft. :- rr`in. - t� •
Industt al/Commcrcial DRcsidcntial Water Supply(shared) •;18.GROUT. •- • •• • :
Imgati0n .. . • ' • •. .. ;- ' . . :. . . • -FROM • • .TO ' MATERIAL' : _'EMPLACEMENT METHOD&AMOUNT".
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Noti-Wat;erSupply Welly .. it, .I� ' -r
Monito$ing . Rccovc ; � ft � t�dill e�C V'�L
Injection Well: . .
Aquifer Recharge • , Doroundwater Remediation
Aquifer Storage and Recovery Salmi Barnet. 19.SAND RAVEL PACKif applicable) ' • •'. -_ -
Di Salinity /G ( pp )
c D' tY . 'FROM ' .TO - MATERIAL . ,EMPLACF.MENTMETHOD
. . Aquifeq:Test OStormwater Drainage -
Experi ental:Technology Subsidence Control "ft .ft.
Geothe ImIal-(Closed Loop) - . '. • •°Tracer • - ' • .•- ' 20.DRILLING LOG-(attach'additional sheets if necessary) ' .
- " • Geothermal(Heating/Cooling Return)'.- f Other(explain under#21 Remarks) 'FROM ' To .. DEscRlrrtoNteotor,hardness,roivrocic type,Rroin'elm,etc.) . .
• 4.'Date Well(s)Completed:©:?7- Well ID# ' IO-k-. I'. • ... • .
�: " . . il_�y . _ft: �f�1?/�-�Cad '
•Sa.•Well Location:: • _
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ft ft
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PC17).414 e •1-I DwIn t 5. :.• • . .. :it tr '
• Facility/OaincrNamc • • ' ' • Facility ID#-(ifapplicable) r.•
-•:-? C '7 it .Jt!r 14.. . 1.. 6. . .. . •• , ft ft. • -•.:, -
• ' -Physical A dress.City,and Zip. : . • .. • •ft. ft. • �I�V :%, c u2 .. .
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County... Parcel Identification No.(PIN.).. •• 1. G::.+y s.;d;'y
'. .5b.Latltt de and longitude in.degrees)miniites/seconds or decimal degrees : : • - •' I. • - • ,. : '
. ' Orwell field;one lat/long is sufficient) : 2 2.Cerfdi one. I•
6.ls(are)the well(s) Permanent - or DiemporarYSignature o Cclfiled Well ontractor Date
9p signing this jnrni:/herebY cerljfI t/tai the nell(s)'sac(were).eanstracted in accordance
. • 7.Is this •repair to an existing well: DYes or,A10 . . ' • with 154 NCAC 02C.0100.or'ISA NCAC 02C.0200 Well Constractton Standards and/rat a
(Miele a t ep air,fill inn known.well constnreiion information,anil'erpiain the aotui aojthe. copy ojlhls'record this liven provided to flue well owner: :' '
repair wide•#21 remarke'sei•#on or on the back of this jorn. •. P
23.Site diagram or additional well details:
8.For Ge probe/DPT or Closed-Loop Geothermal Wells having the.'same • this e:;fo prrovide additional.well site,details or well
You may use the back of
consttncti n;only 1 GW-1'is needed: Indicate:TOTAL NUMBER of wells construction details. You may also attar additional pages.if necessary. -
dnlled:.. .� SUBMITTAL INSTRUCTIONS
9:Total ell depth below land surface: .�7• •(ft.)• •24a. For.All Wells: Submit this Itorm_within 30 days of completion of well
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For multiple wells.list all depths Ifdii ferent(example=3(d)200'and 2(d 100') • • construction to the following: I .
10.Staticiwater level below top of casing:' - . • . • (ft.) Division of Water Resources,Information Processing Unit,
Ijwater ley its above casing use +�• - 1617 Mail Service Center,Raleigh,.NC 27699-1617
11.Borebile diameter: • (O- (in•) 24b.:For Injection Wells: In.addition to sending:the form to the address in 24a
• .above,'also submit-one copy of this form within 30 days of•completion of well
12.Well construction method: f rz .4'mill construction to the following: I
(i.e.auger,rotary;cable direct push,etc.) :- I
1 • • -- - ' • : Division of Water.Resources,Underground Injection Control Program,. • •
FOR WATER SUPPLY LLS ONLY: • 1636 Mall Service Center,Raleigh;NC 27699-1636' _
• • 13a.Yiel (gpm) . Method of test: 19 h:4 24c.For.Water:Supply&Iniection.Wells: In addition to sending the form to .
- the,addresses)above; also submit one copy of this form within 30 days of
I3b.Disi fection type: 11.774• ' . Amount:16,.. • bZ . . •completion of well construction to':the county health depaitment of the county,
. .. . where constructed.
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Form GIN-I North Carolina Department.of Environmental Quality-Divisionof Water Resources ' Revised 2-22-2016 a .
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