GW1--01309_Well Construction - GW1_20240229

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WELL CONSTRUCTION RECORD:(GW-I). .. . .- Prfnt Fonn
Forinternal Use Only:' • I
:1.Well Contractor Information:
Cl1riS •
King
• • . 14.WATER ZONES' • • • . '
Well Contractor Maine FROM'. TO . DrSCRIPTION"
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.2080-A. . 90 ff. 51 dt. Vz 1 •:6- l
. 'NC.WellContractor Cettifieation Number•
' . IS.OUTER CASING(for muiti.casedwells)OR LINER(if ap !kale). 'Aqua Drill Inc. . : :FROM' • : .TO. -. .DIAMETER• •THICKNESS . ' MATERIAL
CompanyNanie �' ILI .�O ft. ��•1�L f •to.
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�,z 1.�•pi vi,G
(r .: 16.INNER CASING OR TUBING:(Reothermal closed-loop)
2.Well Construction Permit.#: - I i1 ,J 2'. .. - • FROM . .TO DIAMETER - THICKNESS '. MATERIAL
• List all applicable null construction permits.(I.e t/IC,County',State;Variance;etc) it'' 'ft. . In,
3.Well Use(check well use): •
Water•Sapply Well: IZ SCREEN
Agrienitnial' • :FROM - TO. - ,' •DIAMETER:. SLOT SIZE THICKNESS 'MATERIAL: •
,OMunicip"al/Pablic . • .. f ' iL In.. .
• Geothermal(Heating/Cooling Supply)' : Residentiaf Water Supply.(single) • .
:R. ft.: in ,
Industrial/Commiercial, : IDResidential.Water Supply(shared).-'
irigation, • •
FROM. TO - MATERIAL• 'EMPLACEMENT.aIEROD&.%M•O• UNT Nun-Water Supply Well: ��p
Monitoring- Recov. 'n:.a�d .rt. ifhl ' • . 1'J ...
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�. n, tt,
Injection Well:
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Aquifcr.Rccharge . - . •DGroundwatcrRcincdiation - . • •R•
Aquifer Storage and Recovery: Salinity Barrier 19.SAND/GRAVEL PACK(If applicable)
_• FROM - ..TO' • .. 'MATERIAL • EMPLACEMENT METHOD '
Aquifer Test- ' 'QStornwater Drainage rt: R
Experimental Technology OSubsidenceControl •
• gi, ft,
Geothermal.(Closed Loop)• °Tracer 20.DRILLING LOG(attach additional sheets If necessary) .
Geothermal(Heating/Coaling Return): •f Other_(explain under#21 Remarks)' FROM' fO ' . 'DFSCHIPr 0l1(eclor.4srd■ev:sulOraek type,gran she.etc,) .
1 a ft: 3. .•ft.- iZe -e.L4/ .
4.Date.Well(s)Completed f L) "�e yell w# n.: ft.• • • 3S 5iidd jZa:clC.'.
Ss.Well Location:' R
•• 35 'ft. I.oc:. •. ,zl�anJ.� e
.t;sA—Dp it i tt. 't i7C c C
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Facility/Owner Name • . •Facility IDS(if applicable) •ft: ' ft: r y q.o�
. . ' �",��.-�is.��®,�..�� . .�
0611 C i urvoviJ q)► :IZa• .E L, r: rv.:t .... : • R,: • »�
i . y,! ,;.�Q
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Physical Address:City.and Zip . '"ft.• : . • ' ft.: : ' L U .4.V-rtl 4
. e l5(AJL `1 . 21:REMARKS- t UZY •
'County .Fake ldentif cation No.(PIN): ' ..
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.: 'tluror..,..
.Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:- y
. . Orwell field,one let/long is suficient) . •
- 22:_CerNtication: •
N •
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. W.`.. V.
••6.,Is(are)the.well(s)i Permanent.' or DTemporary -Signature of Cc 'Sad'Well Contract - -
• 1 . Date.
-By signing this jinni,Cherehr cerOfy that the'urll(s).mu(litre)constructed Inaccordance'
7.Is this a repair to an existing Welk. ®Yes'.or,peNo ' "with 154:NCAC 02C..0100 or 1SA NCAC 02C:0200 Well Construction Standards and that a.
Ifthis Is a repair,.jill out kimun well construction h formation and caplatu ilm.natitre of the copy ofthls record has been provided to the well owner.repair under#21 remarks section or on the back of this form.. -
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• 23.Site diagram or additional welldetails: - -
. S.For Geoprobe/DPT or-Closed-Loop Geothermal Wells having the same• . You may use the back-of this pageto•provide additional well site details or well'constnrction;.onlyl GW-1 is needed.•Indicate TOTAL NUMBER of wells: 'construction'details.'You may.also attach additional.pages if necessary:
•drilled: . .
SUBMITTAL INSTRUCTIONS
9.Total well.depth 6elow.land surface: 2d's� . • l
For'meltiplene//cI/ctoildeptiuijdierent(example-3ag100'a,d.2 Joo') (ff) 24a. For All Wells: wing: ahis form within 30 days.of'completion,of•well .
• construetion to the following:• j ,
•10.:Static water level below top of casing:. I •
. f=Bier level Is alioir easi, use"+" (ft.)
1 ,� ( Dlvision'of Water Resources,information Processing Unit,
/` 1617 Mail•Servlee Center,.Ruleigh;NC•27699=1617
.11.'Borehole diameter: Cta • (in.) ..f •
24b.:For iniectlon•Wells:.In addition to sendingthe form to the address in 24a
12,.We11 construction
.method: /►Z �12 r�.1 .above,also submit one copy of this&fonn within 30-days of completion of well•.
-(i.e.miger,rotary,:cablerdi act push,etc.) • • - - construction fo the'following: '
FOR WATER SUPPLY WELLS ONLY:'. . . 'Division of Water Resources,.Underground Injection Control Program,.
:1636.Mail Service Center,Raleigh,NC 2709961636'
13a:Yield•(gprii) Y`t • Method of test:, l elk
'.-1- 24c.For Water Supply.&'inieedon Wells:.In addition to•sending the form.to
/ the'address(es) above,.also•submit•,rone.copy of this'form_within•30 days of•
136:.Disinfection type:;/ i�. Amount:: (� Z. .•completion of well constriction.to"the countyhealth.de actment of the coon
where.consttuoted.'
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Faim.GW-1 .:
North Carolina Department of Environmental Quality-Division of Water Resources-' -'Revised 2-22-2016