GW1--07807_Well Construction - GW1_20231201

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WELL COligtRUCTION RECO I''IP (GW-1) For Internal Use Only:- '- • r-
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1.Well Contractor Information: . • . . . , . . . . . . . - ...
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Chris king.. . . .. . .. . .. ., .. . . . . . -14.WATER ZONES. • - .•• • • ., ' . • . - - - 1- - . - - .- - •: ,
'FROM " ' •TO ' . - ' •DESCRIPTION. • ' - '' ' . - '. --- • " ' •• •
-Well Contractor Name
• j4i6 ".• 16 / ="-. ' I-5-1.61-Pi.i' \ . -.. . • - . : ... .
• • 2.08,j4, • . • • , . ft, ' ft.
NC Well Contractor Certification Number .15.OUTER CASING(for multi-cased wells)OR LINER(if applicable). • !. •' . . . . "
Aqua Drill,-Inc. - FROM- • -TO' • - •DIAMETER ••THICKNESS • •• 'MATERIAL• :: • •' • • .
. ' , . • . • ' '', • . • -; - 2-• - -.. ' .• . . 0: .ft..• ..e..4, ft. 6)7.4:" n; spiz;z.•1- :: pi- )ic , I.,: • .
Co:r.pany S'',!,,,- • ' -
:M ANNER CASING OR TUBING( eotherznal de-sad-loony - ' : - ' . --- • •.• •
1.1.Vell ConstiuctiOn Permit it:4):<-6,2L. )(....4,/ei.N,I.A , . ... .. , FROM • I TO . • DIAMETER • 'THICKNESS •• ' .MATERIAL - • . ' .
in' " ., - " ' • " , .- • -. .
• . 1.i.o E.II.o.otieythk tall eonstrite:(an permits(i.e.1.11C.Counts.Stale. lance ft.-: ' : . ..ft.' -
.3.Welt.thie,(dwelt Well use): .
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ft ft iii
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Water Supply'Weil:: . . .
'FROM. • .TO • •. .• 'DIAMETER SLOT SIZE.• THICKNESS •MATERIAL•
DMinticipal/Pbblic- , . • . -: " , . • :It -- -:. .ft; . ' . in. . . • . . ' • . •• -: ''.. .- • .'. ' . •
.,kiccr.Tiwrnol i 1-1C,Mag,Coeling Supply) ik,eici.entigl.Watei.8iipply(Single) . ,. • ft:. . ft:. : in. ; : - ' - .- • , . : ..- ; • 2 . . : :
Inch,. :a:(.:....m mere ial DROideptial Water Supply(shared) IS GROUT
ilr..mfli.t o• . • . . . . . , . . .'FROM•- - I TO• • . : •I'MATERIAL- EMPLACEMENT METHOD&AMOUNT
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tt ftik; .
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Nrsit-.'s.-..'nsz.vi,, i vvc•ili • • • -
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• I-iNiopitoco.I.4 . .. • . . , F.7.1kocovor)i • :. • . . . • . -. : .ft.
Irak:can Weil: " ' . - . - ' ' • ' . " : " .. . .• ' • • ;• i...ff. . .. ' 'It• :-- - • . •
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IL:2.ALI,life,-.:..cliarge •OgrOundWater gernediation. • . • •- . ' . • • : • ' . . _ ,_, . . . .
. .19.S.4.ND/GRAVEEPACK(if applicable)' . - - .•. -- --- - - ... ••• . •• .
kcitilrer.4torage anti Reebvery OiSalinity Barrier ' - FROM- ' '- TO' • • -' I MATERIAL' . .' . . 'EMPLACE.1%1ENT METHOD• •• •
77_,,..T.,::--:- ....•:' .
.7:,•;',. . • . ' •
• : '1 c..tl l -
• DIStorm*ater Drainage ' •ft. • ft
per.n-• a echnology . I .
OSubSidence Control: ; • ' ' • -: : • if, - • fr!.1 .. :. -.. .'. - • •
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• ' r7.(7. t).::r; ...,-:-.i(..!io sett Loop). ' ' L G.iTracei . . -' . - 20.URILLINLOG(attachidditIonal sheets if necessar.)' ,. . " ' .- ' ..• . ' ..-. -. .
F.ROM•.: 2 ' TO.. . . I.DESCRITTION(color.liard.ness:soil/rodk type;grain Sin:etc.)
1:Cie:;•:,_•:•• :.... I 1;:.tilv:,/COOling Return) -171,10ther(explain under#21.-Remarks) -
.. . ,..?! 0.*. fi. S. . ..it.-1 gea .d.)A y : . . . . : : . . •
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- . 4 Dare Wolt(0 Completed://''./Li''2 Well116# C.
)0#44. - I.g - . : ..ft'. 80 "' 1 SA il):8 .)2c1c C:--: . . . :. '. ... • .. '.: . • : •
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. • SA. Cr!. 1 r:.:nrit.a.: • . - CO .". 12,5""- I Ride dini tb i A.e • '.. ' . - : . - .
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- . r,,,iii r),,,,,r N,,,,,e . . . Facility ID"(if applicable) • :• ..•. • . .• ft'- --ft. . -E • ('''‘• q., "31'.:7 -..,.. . - " :- • .
s,-,...-q ...-. .,, .. ..i,' ,..,,, .... .. - :-.,It il. ,i
1334____geActilt ' ci,,47 Ae Rivo d.I.e.:144/4-0 - • • • • - - - V. S.,
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Pitysicttl..saldrer; City.and Zip - I 202• • • . . " '.
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igthM4 . . . ..21,.REMARKS • '7•• ' ... • Irsfr.:-?••;:::-..- --" .... - - : ' • • — - -. - .
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(GuntY • .•Parcel identification No:(PIN) .... -• - . . riVilc.,,,y;,--„;, d'.'-
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§13.Latitude and longitude in degrees/minutes/Seconds or decimal degrees: . .. ' .- . : . .. .. : - '. . . •.-, : . ..
. (if well field,one hit/long is sal:ticient) 22.Certification: .
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• 6.lc(arc)the well(i6erManent or OTelimerary . Ignattire of Certified Well Cot tractor -' • - . Date.
.By-signing.ild s;lbrnt,I held)).rertift,that the yell(s)was 6 vire).cynisinicred in-accordance .
7.Is this a repair to an existing well E3Yes ort&o . . . . with 154 1VCAC 02C.0100 Or 1,4 NCAC 02C.02(70 nil Constriiciion Standar&and that a
If this is a rcilair,fill inn knolen well eonsu'llesion hifirmenion and explain the nature oldie " col).rnithisreenril'ILLY been Priitided In the well owner.
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repair under#21 reinark. Section or on the hack of,hisfinin. . .
• diagram 23.Site or additional well details:. . . . •
S.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
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constructio only 1 CiW-1 is needed Indicate TOTAL NUMBER wells . construction details- You niay also attach additional pages if neeessary. • -
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. • • SUBMITTAL INSTRUCTIONS. . .
9.Total Well depth below land surface: :2,1.5'7. . . • .• 014 •24a. For All Wells: Submit this forth within 30.days of completion of well -
Far multiple wells list all depths if dtikrent(exaniple,30000 and 20,100) ' ' ' construction'tO the following: • .
10,Static water level below top of casing: 30 (ft.) , Division of Water•Resonrces,Information Processing Unit,
• If railer levet is above eesiag,use"+" i 617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: • • . .. .. .(in.) . • - • - 24b.For Infection Wells: In addition to sending the form to the address in 24a
.4 . above:also submit one copy of this form within 30 days of Conipletion of well
12.1%6.1 construction method: Jr)P cl mi )1.. - - - - - - construction to tile following
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- -(i.e.nu .rotary.cable.direct push,etc.)
FOR WATER.SUPPLY WELLS ONLY: • .• ' - •1 i • • •• • . Division'of Water Resources,Underground Injection Control program,
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1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gprn) •. . - Method of test: t51-cin 4-. . . 24c.For.Water Sunnlv& Injection Wells: In addition to sending the form to
1 3 b.91,it rc,i-.10 P'..'yp e: ii Amount:../.07_,___O Z• completion of well construction io the county health department of the county
- where constructed. i
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Fen:,CW-1 North romlina lIpnartrnent of Pnvimnmonoll rittitlity-Ilioti.ttoo of11/tver TiperilIrro'c 17....,:vori 1_112)r)1 A