GW1--00992_Well Construction - GW1_20240209

1
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WELL CONSTRUCTION RECORD.(GW4) For internal Use Only: I. PrInYFofm
•I.Well Contractoribiformation:
•
Chris.King , , .
14.WATER ZONES E.
•WcllContractorName • • FROM • TO DESCRIPTION
2080-A rt. ft. . 1 . .
ft..
:NC Welt Contractor Certification Number
-. -.15.OUTER,CASiNG(for mull-eased wens)OR LINER(Iran !feeble) •
.Aqua Drill;.Inc. •FROM- . .To- . . •DIAMETER' •-THICKNESS MATERIAL
ft.' ft. A
Company Name : .D. J L, , .65k. In: .r,A; ' •• /C� ;1Q *89
�f / � 16.INNER CtiSING OR TUBING(geothermal closed400p)'•
2..Well:Construction Permit#:- WET O/'/$/• - FROM. • . TO'.' • .DIAMETER - THICKNESS•. 'MATERIAL'
Zistallapplicable well construction permits(i.e.UIC,Cowity.•State.Variance,etc.). .ft. •ft.' ' ' ;" in:
3.:Well Use.(check Weil use): : ft.• . :.H.. . In.. '
Water SRPPIY Wen: •
17.SCREEN
FROM . -•TO DIAMETER • SLOTSIZE THICKNESS :'MATERIAL'
Agricultural Munici al/Public
Q p iG. ft.: •
Geothermal'(Heating/Cooling Supply). • a1 Residential Water Supply(single) ft.. D.- : •In.:
Indastrial/Commercial DResidential Water Supply.(shared) 19:GROUT,
• Irrigation . - . _ • FROM' . TO. .. •MATERIAL. EMPLACEMENT METHOD&AMOUNT •
• Noti-Water Supply Well: •
/� ft._ ^r D,n.. '��L-JT L jyi''194"/:7/ '/f7/&.
Monitoring' Recov ' �l '��y
ery R R.• . �+•
Irijection'Well: /f�J97tiS"r7� d:
• Aquifer Rcch ft.: .ft.
9 argc ElGroundwatcr Remcdiation
A tiifer.Stora a and Recovery ...19.SAND/GRAVEL PACK(if applicable) • . . •.: . . .- ..
q gery- DSalinity.Barrier: .FROM . TO • ' MATERIAL : . - .EMPLACEMENT METHOD• '
Aquifer Test. OStorrnwaterDrainage' R• ft. .
E erimental Technology 'QSubsidence Control 'ft. ft:. .
Geothermal(Closed•Loop) . iDTracer 20:DRILLING.LOG(attach additional Sheets if necessary) ' .,.. '
Geothermal(Heattng/,Cooling Return) :,[Other(explain.under#21'Re:narks) momTo 'DESCRIPTION(color,aerdness solutockNpe;(rala size,etc.)
ft— fi:
�/ • �' g Ces�y .
4.•Date Well(s)Completed: ///2�d-�' Wen) IL. ft.
5a..Well-Location: IL. n•
fL - �Or/. /rfi tof/fL4•.
/' ` R) Sla
•• v/ �i i. .. t. :ft.
i .
'Facility/OweerName Facility lD#(if applicable) • R ff• "� i . •" •*"
�aJ q _. e r la®!
t 't %SO Ir.:a V 1.�/s.,'
1 1 e/9/<4. d e`lP -c syi �'LLlf..bG '�.7.57' - R'. : . �`'
Physical'Address,City,and Zip .ft.. ft.: • FEB .0 9 2024
44/1-4/ 21.REMARKS ' -
County. . .Parcel ldeniificationNo.(PIN) tnform:a OE'i)iProo' •�Ufik
Sb..Latitude.and longitude in degrees/Minutes/seconds or decimal degrees:
is UWw k It
(if well-field,one lat/long is sufficient) 22.Cart en on:
6.Is(are)the well(s) rmanent. or:(Temporary Signature ofCcrtificddcll odtmctor- ' Date'
By.signing ibis fwm,l.herebv ceis(/j the;the uell(s)•nut(were)constructed.in accordance'
7.Is this a repair to an existing well: •QYes• or Vo with ISA•NCAC 02C.0100'or ISA NCAC 02C.#200 Well'Constiuciion Standar'ds'andthet a
Ifthis is a repair,fill out know;well construction hrfaroration and explain the nature of the copy.afthis record has been provided to the well owner.
repair under#21 remarks section oron the back edits form:
23:Site diagram or-additional well.details:
8.For Geoprobe/DPT or Closed-Loop ceotherinal Wells having the same You may use the'back-'of this page to provide additional-well site details or well
construction:only•h GW-I is needed.-Indicate TOTAL NUMBER of wells consttuuctionrdetails.'.You may also attach additional pages if necessary.
•-tailed. SUBMITTAL INSTRUCTIONS
-9.Total well depth below.land surface: - : to a (n•) '24a.-For All Wells: -Submit-this form within 30 days of.completion of well
For multiple wells list all depths ifdifferent(erani)r/e-:3 200'and2®l00') cottsttuetion to the following.
10;Static water level below top of casing: 30
Yfn;ter levelis above casing,use^+' (ft.) Division of Water Resources;information.Processing Unit;
1617 Mail Service Center,Raleigh;NC 276991617.
11.Borehole diameter: (in.) .24b.For Infection.Wells:•in addition,to-sending the form to the address in 24a
12.Well construction method:
, above,also submit-one copy of this fonn.within.30 days of completion of Well
-(i.e.-auger,•rotary;cable,direct push,etc.) constntction to the following: i
' Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:.
1636 Mail Seiviee Center,Ralei gh,.NC 27699-1636
13a.Yield(gpm). . ;01"/' Method of test: • 24c.For Water Snook&Infection Wells:-In addition to sending the-form'to
' •the.address(es) above; also:submit',one copy:of this:form within 30 days.of
13b.Disinfection type: 7,10 //7! -Amount: /le 02, .. .completion of well'construction to the county health department of the-county
where constructed.
Form GW-1 -North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2,22-2016