GW1--00071_Well Construction - GW1_20231218

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.. WELL CONSTRUCTION RIECO D(GW-1) • For'Internal'Use Only:" • : • '
1.Well Contractor Information:'
Chris King • . .
14:WATER ZONES: - "I
Well Coiniactor Naive ' " ' -•- FROM- TO ' • DESCRIPTION
2080-�, 1 .e4 i I`'.,I t
:fr t.• .ft.
NC Well Contractor.Certiticatioii Numbar'
"UTER.CTSING(for multi-cased wells).OR.LINER(if ap li cable).
-Aqua Drill,- nc:.. • : ; .. . • FRO O DIAMETER ' . -•THICKNESS; . .
MATERIAL.
Coi• i
:
e . •ft. •cf.1 $:. 6 YL4.i in:• '6 0 I2 . ).:'.' -G'1 1/ . '
rp_riy\an7 ., ."
],. ,,1 16:INNER CASING OR TUBING(geothermal closed-loop)' - _
• 2.Well Construction Permit#:.�`/[, 7Ct::1 Ck1V '.1. FROM ':• :TO '. DI.4rIETER '. • 'THICKNESS-:--MATERIAL '•
list at!,appliccihle tic!!canst!aciion peilnits(i.e.UIC,'Copnt,i.State,Variance:etc.) •. fL: ft: .• ln.'
3-i/ell:a se(clieci:tit ell nsel:: . • ' : • • .: : , ' .: • • .-ft ft• .. : in, . : •.: ' .. • . ' .
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. Waterppl Suy well:. .- .. . .. . 17 SCREEN ..• ' '... . .- '. . - • . , .. • • ' .
FROM. • TO -.DIAMETER SLOTSiZE: THICKNESS " MATERIAL
. grleUItural:' • : ' • •• ' 1VIunioip aVPubiic .. . _ • :
... � P ft.. 'fC . : -in..•. •
Gcothernial(Hcating'Cooling Supply) •tcsidcntial Water Supply(single) :
• lindustrialiCnilintcrcial " ' Residential Water-"Su 1 hated)
. P• y(s "
18 GROUT '� •'
hYl •rl'UFt . ' ".. - . . .- . . .. FROM.. : TO. MATERIAL - i - -
1,_ -EMPLACEMENT METIIOD&A"IOUnT.
ie'ar."a;er:Siipt lvtVell: .. - .. • .. . :ft. lb:::ft.;
. 17G10.4/11i4e. .dh't.PC... • • .
- ,IMonilnrino. - - '::.• • f Rccove•ry. .. '• ft.. :•• - 'ft. • . • - •
Injection Well • ..•. ,. . ' . :.. • • • .
,,-t)uitet Recharge :, iGroundwater Remedlat)on•: - ''
` 19•SAND/GRAVEL-PACK(if applicable)' '
. UlAquiferStorageand• Recovery •
"Salinity Barrier" FROM" • :_I-TO• •. • I MATERIAL.- _ . FMPr..4CB"1F.NT"METHOD. '
A .;ii';r?c - �IStormwater:Drainage.•
- s : � .ft. fr..
1E perimenral 1 ec1mology": DSubsidenee'Control. •.. • ' . -. . . .'fr ft: . • :. ••. - ' . • ' ..
. Get heraiai'tClosed Loop)' Tracer- 20.DRILLTNG•LOG(attach additionallsheets if necessary)',. ..
'P FROM.. 't'o•-.: - - •I' DFSCRIPTION(color,hardness;so,Urock.t p4.strain sloe:etc.).:
17:Gect;ictii:al ,H;ating/Ceoliok RetuihJ.. CiOther,,(explain under#21.Iteinarks)
9 • ft: ft'
:---)stn •�'Il(s)Completed: 1 L=•21 •?Well ID# ' -. • ' . ft • ft. •i • -
. t.lW cil 1 d Masten:.`.: : : : ' 2 8 . . �J I : '
• . . . • :C � i F�'�ft. ! I J�V�' 'k�9''1?i�l�e7 e. - . . • • -.
. ft. ft.
. 'iv 44 nc'" - :. :.Facility ID`(if applicable) • • It •i ft.'
3•��S !1 t j7/�` pOd •c 4 • •)�a,13od >i:-t A i fli •rt': 'ft. : : ft. .•. • C •'•^�^;^-a• • A •r—•r-ti •• :• ' '.. .
- P i.r!.,idr ss.City:Anil Zip • - ' ' . ' It r ' ft:.! cs., ... -+);;;:>i '° .1,,.•, .
AMA, C� 21:REY- .-
. • GEC 1" 8 2623
Coan:e- ' •' ' -. Parcel Identification No:(PIN):. • - • ' • ."
Sb:t aiiznch:and longitude in degrees/mi'utes/seconds or decimal degrees: • Irt'6f'"°'`' Ca af'_i.;..:Nrr :(%Y;?�. : - _
• (ifiicli He ld,one:at/1.ag.'ia sufficient)' - . ' .. • - 1; , •.D't-gQ-i: t)3. -'
• 22.:Certification:
6 I t.tt.tie�ie!r(sl t'r,crmanelit or Temporary Signature ofCcrtificd Well Contra or - -. Date. . . •
Br sighing d ii,Jinn-I hen*:certilkildi,t the}trdl(,r)irrn(u•ei•c)cnns:riaiad in.accortlanee'. . '
I: :Ili!is t:etr .....'it}an.eslSii_tig ucll }+ ' es or. \o - u•idr'/5.4:1tC4C(PC.0100 in 154 4yc.de.-pc.o2grove.g.CinisinictimrSteyid.a.rdfai4/that a
1 tid s: _, ,;1: ' Sri.r kl:aria tell cahsii-in litin i ri,iwiulian and egrlaiit the itnlnra r f the i•riAr'Olds t•ernrd Ira,Gee,prni•ideil at t e troll owner. :. ..
kph; :: r-intI}".3Si'i'riaH pi•on the(Murk cif this fn in. - . ' . ' .,
23.;Site ditigt ant or'additional yell details:..
5.1 ut•G:rthr,tlte/LiPT oi Closed-Loop Gcothernial i`ells having thesame You may us•e the back of this page!t•o provide addition•al well site details'or well
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- - ,•nn :t,,"cil;•l.(�1V-1 is•needed. Indicate TOTAL NUMBER of wells " constntetion details. You may also.attach additional pages if necessary: : • •
drilled: • .• . :
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SUB RTTAL'INSTRUCTIONS
•- 9 Torn)as, It de tl:below land surface: •i - • • . . (ft)' ;2 a Fret-A'1.Wells.• Submit this,form Within 30 days of completion of well . -
For rr ,•4 t. 'a riii dopM,ii dJfei•cnt(example.-34122UD.and 2(c UQ')`, . : ,consnitction to the following: - • " -
10.• •
Si t r•a at tc 1 b loty top'of'casing: . : 2— .. . •(ft;) Division of Water Resources,
Resoces,lfnfoi mation Processing Unit, ..
it, r c '.^c ts•ril,vrc r,v t •us[+
e. ''•+" • • 1617 Mail Service Center,Raleigh;.NC 27699-1617
. 11:5.;rt•i;cie di:m titer: .• : (in.) • ' '241%For rnitetio'n\'Vella In addition to sending the form to the address in 24a -
I. above, also submit one copy,of this form o. ithin 30 days of completion of well
12.'.ti.is c„i;tr.,c.ion.Meth )Z;Met-tied: frz.% I 1•- -- . • " ,construction to'the following: • '. -
r:a ..,_;: •.,aide.direct push,etc.t
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• Division of4 later•Resources,:Underground•Injection Control Program;
L)ise;--41,�z..SLPt1:Y1,VEL_L:SONLY\ : - " ' '1636 Mail Service Centcr,Raleigh,NC27699=1636
•1-n.; ",�3'1 r".r--'..—_.21' 'Metleod.of test 5•I Cj k J t: .2.4c..Eor.Water StippI &Iniecti�Wells: In addition to.sending the form to. .
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the addresses) above; also subiuitl'one,copy:of this form within 30 days of
"h• _• I TN Amountt.-/'' _•6.` .. . completion of well construction to the county health department of the.county
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r.— _ . . where constructed. I •; ' .
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•-• North Carolina Department of Environmental Ouaiii r-Division of Water Resources I• rai•icnti 9_97:f/iI6