GW1--07390_Well Construction - GW1_20231117

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: . Print Farm;:.
'WELL CONSTRUCTION-RECORD(GW-1) For Infernal Use Only .1 Well:Contractor Informopont .
::Gry Thompson
Well ConttaCtOrName FROM TO DESCRIPTION ly
4418=A • n w- l?• (-�-'' 'k..e
NG Well Contractor.Gerttficatton Number • _
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IS.OUTER CASING(for.malf cased,wel s)ORLINER(if tip ble)
. A•qua Drill, Inc . :'.' • ' •.. . . - • ' . . , FROM To . -' -DIAMETER:_-. THICKNESS . MATERIAL.
Compan:- • - • . .• 0 ft. Gi."15'• In'_ .5 C)cI' _ uc .
.. 16INNE CABIN
2 Well Construction Permit# -mom- R ..To, TUBING'. ERthe'rmal
' 'it
• � _ OR
.last all applicable null construction permits 0.0.'111C County Rate Variance.ate.) • ' 'ft.: R : to T> RS
Oop ,.
- . 3 Well Use(check well use)c .- • . •' . '- '.: : . . . , : . . ft,_ ft: , .. •m.• .. .
MATERIAL
Water Su -
a Cnuppl ETER. SLOTSIZE THICKNESS - MATERIAL
�M
rcrpal/Publ(o
• FROM 70 DIAM
thennai�eatin /Coolrig Supply) dW idenhalWater3upp,y(single)
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' lndustrial/Commeicial .- ' '
• : . �IResideatial Water.3uPPlY{gad). 1&.GROUT:'.::
rrri�atuon' .. - - . •• "'FROM • •TO MATERIAL • EMPLACEMENT METHOD.&AMOUNT,
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Non-Water Supply Well - ' ft' `1�• ..b, t • .
. . .Monitoring Recovery. e,.hw. .• :.p� .�{�.; •
lnje on Weill • tvk:Cpy . .
.- fr. R.:.
A'q�u1feiRecharge i (hour dwater Rem edtation ..
' 'i:- 19:SAND/GRAVEL PACK Ofypttcable)• A Ifer Storage.and
. ' . .�. Recovery• ;, I�$aiinity Barrier _ - FROM-• : _TO �tNATERiAL 4OD ..
:• . - : Aquifer Teat '. . ' : IIStormwater Drainage • - 'a. ' • lZ• - ,:
: E.-1 eriri►ental'Tech>mlogy; • . ' :•. . Subsidence Control- . . ' R .. •..R. ','
• :. O. etmal.(ClosedLoop)' . ' IZltacei ', . .- ' . 20.'DRILLING.LOG(attach additional'sheets Ifnece sary)' - _ _ -
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theal(Heating/CoolingRetutn)
rm -Other(explainunder#21Remarks):. FROM TO DFSCR1PTiON(®loatniranen,eommcatvee, use,ete) .
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4.Dr Well(s)Com letedd••t b b`t.,.l. Well D)# fh. • - .
5a.'1yel'Locatton: .. . - . . • . : . - ha.. 4 ��
. . I • 1 , � • 3 �'�to • _
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Furth`%OwnerNante if.
`� Fac titylDit(ifapplied-tie)• •
•0:Oit.:4117�.e'y1 � R. • ;' '.',.,•-, j
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Physical'Address,City,.andZiP ':: 12. n I, 4 _ ; n�
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:REIVIARK9•-._ , .- � � �^h23 .
County" " Parcel Identification No:(Pity)'
'. . -Shi LittItode and longitude iu:de eesintiti es/seconds or-decimal.degrees:, ' ;� "
'.' (if we field,one kit/long is sufficient). •
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22 CerdHcation: i i " • {
6.Is( r'e)the weq(s)&Pernianent. •or.OTemporary.. signature of- . ell • • . . Date
By signing this farm,.l herebjrc rtfp Nrat tile'ue0(s)hvas(were)constraeted in accordance '
1 Is is a repair to an existing well: 'Dias or o.. with 13ANCAC'02C.01110 or 15A NCAC OZC 0200.0e 11 Constractlon Standards and that a '
If figs is a repair Jill out known ire!!constru tion information and explalathe natmr ofthe : copyof'this record has been provided to the,wellaivnes: •_, y:
repair , #21 remarkcsection or-on tie backofthlsform. t
23 Site diagram or additional well detailae •3.Fo1'Geoprobe/OPT or Closed Loo Geothermal Wells ha ' the same: ' you may use the back of this e'to ' .
I P vmg pug provide.additional well site details or well . . .
. constructon,Only)OW-1 rs needed. indicate TOTAL NUMBER.of wells : details You may also attach additional pages if necessary
9.Tot�l.weII depth belot+'vaaud attrface: -' �3 ' •: . '', .(g,) Z .
• 4n For MI Walla:R Submitt.tthis.fo For mu tiple wefts l/st all depths{fdiiferent(example-Spa 200'6nd2@I00) -- : I .Within 30 days of completton of well
on to the following •
10 S I ticwater.level below to.ofcasin
consttactt
.hunter'level Is above`casl P $t - •• (R Division of Water Resonrees,IDfarmatiou Processing Unit,ng use.a+^
1617 Malt Serdee renter,Raleigh,NG 176991617
. 11.Borehole diameter .. pat.)
' • . 241r'For lnleetion''Wells:. In addition to sending the form in the•address in 24a
f2:�Vfll construetloti method:, c-tr�'N ) ,! above,:also submit one copy of this'fora,'within 30 days of completion.of well.
(i.e.auger,rotary,cable,direct push,etc.)• - - • — -- • constmc• t•• • following: 1 I '
- " • • • ' .. . Division of.Water.Resources,•Unde a . '
. FOR1VATEA'SqPPLY WELLS ONLY: •• ' -
. y� .. center;Roleigh�NC 227699.-16361Pro
1636 Map Sernce Ce Vim'
13a Y`eld'(gpm)-• V_- - Method-oftestd • • - 21e.for Water Sunni*&Inieetlon:Wellsr In addition to sending the form to •- •• '
• the a'ddress(es)°above, also submit one copy of tins.form within.30 days of
. 13b Disinfection type .. Amount: :• • completion of well construction to the county health,department of the county
where t cnatructed. j
Forme -1
North Carolina Department ofl3maroun a ital Qualityy-Division of-Water Resources Revised 2-22-2016 ' '