GW1--01298_Well Construction - GW1_20240229

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'PrintY Form
WELL.CONSTRUCTION'RECORD.(GW-1). . For Internal Use Only: I v
• .1.Well Contractor information: ;
Chris.King . . 14:WATER ZONES •.
WeilContlactor Nate' FROM' TO DESCRIPTION
•2080-A -I%( ft..- 1%). • -S. -,-h,•i''1
ft.- . ft: i
: NC Welf Contractor Codification Number '
•.15:OUTER CASING(for niultl-cased,welis)OR LINER(Hip liable)
Aqua Drill,.Ind: FROM' • : -TO DIAMETER . 'THICKNESS.- MATERIAL
Company Name . . '0ft.. .� t fL. 6.�y. in.. �j2•)' •./ l.iC
(,1 or 16.'INNERCASINGORTUBING(teothermalclosed-loop).' ' '
2 •Well Construction Permit# 3 •/ L7�O • - - FROM . TO• '•DIAMETER' THICKNESS• •MATERIAL
•
• List all applicable*ell construe ion permits Be.'I BC.Connoc State,Variance,etc:)• ft
3:Well Use(check well use): •
•
Water Sapnly Well: • 17:SCREEN .'
.D A CnituraL ' :FROM' :TO • DIAMETER .-SLOTSIZE - .THICKNESS ' MATERIAL
gn • •DMunicipal/Public- 'tt•: : ft.. In. - -
DGeothenmT(Heating/Cooling Supply) I Residential Water SuPPly(single)• '
it.; Yt. in,
Indushial/Commercial [ Re identiaf Water:Supply(shared)..- 1&GROUT '
IlIrrigation'. ' . . , , • . . . FROM - .TO' .MATERIAL. ' EMPLACEMENT METHOD&
- Non-Water Supply Well: - R g,. .C.Monitoring'. Recov
Injection Well:
-DAquifer Recharge. ••C3Gioundwatcr Rcmcdiation . . • tt' . , _
Aquifer.Storage and Recovery19.SAND/GRAVEL PACK(if applicable)
OSalinityBanjer. . FROM ' TO MATERIAL E.MPLACEMENTMETHOD
Aquifer Test. DStormwater Drainage
Experimental Technology Subsidence Control:
Geothermal(Closed Loop) - I Tracer 20.DRILLING LOG(attach additional sheets If necessary) , ' - - • •-
OGeothermal(Heating/Cooling :Ftt091 'f0 .DESCRIPTION(valor.naraness.saturorkts c,gralas(se;eh,) '
nn ��Other(explain under#21 Remarks) :O. ft. .5011
4:Date Well(s)'Completed e6 �'�'•' �,• Well
. ' •:a -11. 357 ft.'-1 /Rd 5)le 11 /sec/ . ..
Sa.Well Location R' '32S ,13kC 6itigNI4IC . _ .
• .ft: - -ft. . .,
'Facility/Owner Name' • Facility IDS(if applicable) ft. ft. +m r� �,.e
{� P t' : r�».�A/I�
10 31 1� . v e rrtct: . 1Z.,4 . BRkn M.tA•• r 'C. ' •. •_-• iL. : . . H.-- • • • e`• t � .'
Physical Addresss,Cit,and Zip-, 'ft. _ ft.•: • F t b. 2.0
.Q 2074
Q G:12 N T1.11,1 . 21.REMARKS
•County- • -Parcel Identifiication No.(PIN) ItlfOr fatier1 P,rnsC: .R° i U
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'Sb.Latitude and longitude in degreesiminutes/seconds O_r decimal•degrees:• ' ouli 6
Orwell field,one 1sUlong is sufficient) 22:Certtflca on:.
N. W. •
• . ,.�-.?:2.Y
6;Is(arc)the well(s)J iPermanent -or_-IDTemporary • _ . Signature ofCertific Well ontractor Date.
• By signing(lit font,:1 hereby certify that the null(s)wore(were)consteuctedin:accordance.
7:,Is this a repair to an,existing well •IJYes or fig,Z10. ' . 'with.15A NCAC 02C.0100 or'15A NCAC 02C.0200Well Construc/lon Standards and lbat a•jthts is a repair.fill ont known urll•coitstrudlon.it formatlun and erplaln the.nature of the., ' copy ojdi/.s record has been provided to-the aril owner:.
•repair under#21.rentarkt section or on the back ofihls furor. . - :
23.Site diagram or additional well details:
•8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the seine - • You,may use•the-back of this,page to provide additional well site.details'or well.
•construction,'only 1 GW-1-is needed,'Indicate TOTAL NUMBER of wells: 'construction details. You may also attach additional pages ifnectssary.-
drilled: • . .
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SUBMITTAL INSTRUCTIONSj, •
:9.Total well depth below land surface: 3 J4.2-J - - • - - - (ft.) _24a. For-All Wells:-*Submit.this form Within days"of completion of well
. . Far multiple wells lisl'all depths Ifdierent(example-30200'and:2©100) -
• construction.tothe following:.
'10.Static,water level below top.of easing:. . 3 a - (ft.) Division of Water Resources,Iitforioation Processing-Untt,,
if water level is above casing.use"-+/ 1617 Mall Service'Center;Raleigh,NC'27699-1617
' 11.Borehole diameter: (`per (in.). 24b.'For InlecHon•Well:l:.:In addition:to sending the form to the address in:24a
12.Well construction method:. /71 R. . ' f��i i above,also submit'one-copy'of thisjform within 30.days of completion of-well
(i.e.auger,motery,:cable,direct push,etc.)' construction to'the followings
FOR WATER SUPPLY.WELLS ONLY:' 'Division of Water Resources,Underground Injection'Control Program,.
. 571636 Mall Service:Center,Rtilelgh;NC 27699-1636
13a:Yield • `a'
(gp!n)• • Method of test:,Si 1 Pi'}''. . '.24c.)For'Water-Supnly&lidectio i Wells:- in addition to sending the form-to
the addresses) above,,also,'submit,one copy of this form within 30 days of
13b:.Disinfection type:r '14 I - • Amount::I G• 0, Z.• :completion of well construction to.the;county.health department of the county
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14.
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. . •• where constructed.•
Form.OW-i •• North Carolina Department of EnvironmcntalQuality'-Division of Weter'Rcsourees. 'Revised 2-22-2016