GW1--07810_Well Construction - GW1_20231201

• WELD,CONSTRUCTION.RECORD(GPI-I. . .. .. l..
• • --- - • .• • • •r--
Z For Internal Use Only i
• i.V1We1+1 Contractor information:
Chas King . . _ .
. .
� 14.WATER ZONES l
Well Cdntractor.mine - .. - FROM' TO DESCRIPTION.
: 2080-A ) O fit.. 14 :I.-ft..
I -ft... ,O .
FL ft. ]
NC 1'trell'Conuactor Certification Nurnber
• .15.OUTER CASING(for multi-cased wells)OR LINER(WOlicable)Aqua Drill, Inc. •FROM ': • 'TO " DIAMETER - THICKNESS. • MATERIAL
Cc::.;tar,, .,,,,,. • • •• • fit. .s fir.: ��� i n. ..
-6 16.INNER CASING OR TUBING(geothermal closed-loop) . _
.2•Weill COitstrtiction Permit#:��"`'''•�1 I4. eL ix.) a 3. • 'FROM . I.TO ' .. . - DIAMETER , •• _•THICKNESS- •MATERIAL
LS.1 all a unietthie,cell canstrumion permits(Lei.U/C•County.State,Varia ice,etc) fi, I : .- fit• in: • ' •
3.WelliUse(check well use): . • 'ft. I it. . . : ' in •'
Water Supply Well:•
1 • -FROM . •'TO ". .DIAMETER -SLOT SIZE. 'THICKNESS .I'.MATERIAL-
X Agric'
o It.,4ti. •
. . OMunicipal/Public ft. ft. ia:
Cic 'tcnnil?Heating/Cooling Supply) esidential Water Supply(single) •fit.' . . tn: . f
a fit.
.)itcit'srai Comuerciai• jRcsidential Water (shared) - : •
1
In-i o - FROM ' I'TO MATERLU. ' . -EMPLACEMENI'METHOD&AMOUNT '
P;iaiiia.'•:i(::E.Ici,Nll`Wel):.. .. .. CD fit: .. fit. N ''v4•
0'
1e 1..►'l` 'c
«tMonn, — .. ccovcry ft. . '
ft.
'lajectioh Well: -'
' � �G•Ayatf i2ctharge . I ft. .
roundwater l2einediation
JAgttir`r Jtorage and Recover. 19•SAND/GRAVEL PACK(If applicable): • •
Y Salinity Bawler •FROM' . I'TO•' • ' .I'MATERIAL. • F.MPLACF.\IF.NT-METHOD
• .":,;:::tj :cst DStonnwater Drainage" fit .I. fL
'`.EN•rcrir,ent'al Technology • 01Subsidence Control ,
t, ,,, t cc tosed.Loop) Tracer - . •L 0"DRIr LING LOG(attach additional sheets if necessary)
L G,,r,;:i.L -. . .,leering/Cooling Return) cl
$Other(explain under#21 Remarks) FROM I 'To I•DESCRIPI iO (color,nardnesss soil/rock tope,,_rain size,etc.)
O -ft•. 16 . ft''I gc ' /Y.0 �'I a9 -
tc{'t 'its)Completed:��' Lj' � Well iD# 4. S
flit R. is& fit.
�.r:�; 1,Ir •^::iian: fL•f215-t.•I -)'-/ue. �) �" . .
D ,.1. �Yti't e
C.�-'—!_1uC: (S 12. •
fit. i fL
I-"�. • .' •,' ,'' Faciliii 1D;(it applicable)'
• 1 F-
ft. ft. _ !I•''i'
• 1(l2 j1r � c�-. iKcizrvod it lww� in: =t, ; ft. I
Piyst,...,,:.ut.:,.,.t'ny,and i=ip ft. I fir. ) . . L''_ �y L l)L J
•
/>9t' .' : : •21.'REMARIGS -. - . • • r
LL66�
(a,:r. . v� : ,�•�'Parcel Identification No.(PIN) fib.°: +„_.cam
5a,L.:,:i;t.t and longitude in degrees/minutes/seconds or decimal degrees: •
'
(it weil i Ii!:one:st ong Sc sntiicicnt) • ;
22,Gertitiention: 1-'
. . W `
•
6.1,!a,•: .n:o,ell(s' ,n:•rlranent or.[1Temporan Signature ol�d well Conti, tor 'Date
,Brsigning thi.rlium.I hereby e•erij•Thai the ur//(s)uezc(;w:et..c•ua.`riurcetl Li accordance •
I' ;'i; ; i_; :•tc nil eslsting t ell: .[Yes or P<No with 15.4 ,C IC(QC.0100 ar 151 NC.•IC 02C.0200 iYell Consiriteth».,S!widarrlc and Matti
l;ini:,s 7 :.i,na Aio ii Bell cnuca•itedoo infiuvinrtioo and e.plain the nature of the cal).ilftlric record hex been proridcd to the well curlier. '
A pui•• n.•• - ,,than r section or an the hack elf(lric.fbent.
' 23:Site diagram or additional well details:
S.1'61"C,r,a:i gibe/LIPT at Closed-Loop Geothermal`:fells having the same You nay use the back of this page to.provide.additional well site details or well
t In :, .t :;: 1 (W-l is needed. Indicate TOTAL NUMBER of wells constriction details. You May also attach additional pages if necessary:
drilled-
_ - - SUBMiTTr1L INSTRUCTIONS
9.Total Well depth below land surface: 9 2 J (fit.) 24a, For All Wells: Submit this form within 30 days of completion of well
For in:il iple wells list all depths il'dijlereni(example-3(cr12p0•and 2(d,100')
construction to the following
. 1 9.Static water Ievel below top:of casing: f (ft.) Division Of Water Resources ir.warrr!:-Toi,tc abase erasing,use" ,information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617 •
11,Borehole diameter: . . •6. . ' (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.'Well construction method: -/vJ jz�.�, I above, also-submit One copy of this form within 30 days of completion of well
(i.e.:u_ac.moo,cable,direct push,etc.) •
constn)ctioti to the.following: i
Division of Water Resources,Underground Injection Control Program, •
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(;pro) / 0/Q
Method of test: 5.014- 24c.For Water-Supply-&Infection Wells: In addition to sending the form to
11
the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: T Amount:I 0 completion of well construction to the county health department of the county
' where constructed. j
Forty G\V-I North Carolina Department of Environment.]n,.:,th,._n:.a..;.,...,o.,,..._-n-__".-__