GW1--01595_Well Construction - GW1_20240308

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• :WELL CONSTRUCTION RIECORD(GW4): -
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1,:Well COntrackw:InforznatiOn:• .
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Chris King king. . . . . . . . . . .. . . : -14;WATER ZONES: . : . ' • I. ' .
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Well Contractor Name • .. FROM . ' TO .• . 'DESCRIPTION
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•208 .• :3211'.: 37/ ft.: . AST t6:119;ri.i.. . .. - . . .
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.NC Well Coat actor Conitication Number
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15.:OUTER CASING(for muld-casedWells)OR LINER(If applicable) • .. . . ...
. Aqua.Drill,:Inc.- . . . . . . . FROM. TO ' .. . . .DIAMETER.! THICKNESS' %MATERIAL-
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. '.Company Nome. " ' . • . 0 - fi.... •CA •ft.'• 6/lit'. 1-: ofz..z I - .: • pa...c,.. .
• 16.INNER CASING OR TUBING(geothermal closed-WM
2.Well Constructinn Permit 0:'0:47'.22;•"7:?..) . . . . FROM ' TO. . ' DIAMETER . THICKNESS • .MATERIAL . . . .. .Lk/all applicable wenconstruction permits(1.e.UIC;.County.State;Variance:ma) • " • •ft. : . •ft.: . ' •In.
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•3.Well bie:(check.u;e11 use);.. ' . :ft. .: • .ft. In,
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• Water Supply Well: • ,
Agricultural- •
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• DMIlnicipal/Public ", ' .
OeotherMalli-leating?Cooling SupPly),egResidetnial Watei.SupplY,(Single)• . , I7.SCREEN. : — • . • . • • . .
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: •FROM .'TO' . ' DIAMETER... 'SLOT SIZE • •THICKNESS ' MATERIAL •..
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. ' •*Industrial/Commercial : • 0 Residential Water Supply(shared)'' ' . . .
. .18.GROUT .. - • . • . . . .. . ' . • .'- irrigetioti• . • . . • • . • . . .. .. PROM .:TO' . . MATERIAL EMPLACEMENT METH UNT
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••• Non-Water Supply Well - • • . . ,
" .• ' . 0'.'ft';',Z0-.. •ft-ik-hAii)e :•e;);\l'is:5. : : • -C
it Monitoring . • . • . ORceovcry . . •
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Injection Well:• .
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Aquifer Redharge, • • : Groundwater Reoiediation. • . - . - - . • . .: • ._. • . ,
' . • . ..19.SAND/GRAVEL PACK'(t(applicable) . • ••- . .SIP Aquiter Storage andRecthrery, . • OSalinity.Barrier • '. FROM. . -TO ' 'MATERIAL _ EMPLACEMENT METHOD'
. : I Aquifer Test QStonnwatcr Drainage• -ft.. ft..
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JIEliperiinenM1 Technology• ...OSubsidenee Control.
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_II Geothermal(Closed Loop)• -0Tracer• • . • • 20.DRILLING LOG(attach additional sheets If necessary)•• . • • • , ..
FROM . •. . .. -•DEsc Funioxleolor i hardness.salt/rock hmo.grain lac etc.): ' •
:, ...:Geothermal(ileating/COoliiig Return) :•Inbther(explain under#21-Remarks) P
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. .41- • 4, . . . 0...ft.. ' .4' .-:ft. g .diA 1 ' • . . . . . .
4.Date-Well(s).CompletediP0- .,
2- (--7 1°C11 Well no • . - .•St :".' Cl S'• ft. '• 5AN:d-...1.0 c(7. : . . . .
Sa.Well Location: • * 9''3 ' ClaVt...: 43 to c; .6r2 AA),i.N'e..
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• FacilitiblXvore.Nome- . . .Facility ID#(if a/Mlle-able) • • . IL., *- : .It'' • * . • :'' . . " - .
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•gtAll- •)*IirC' s .0 11*. ila*-r.J.,*100(1-CW. .,N,) ':- - . • • •
• t • :: . IL-: : • . f!';• :.. .. : [J--e.. .;:-.7(:41-4 At/1-1_._) . • : .: .: ft; • .. •
. •Physical AddMss,City,and Zip i I.
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. • " 21.REMARKS:- .• : . Mmr(-6 (4.. 2624 • .. :
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'County• Parcolliontificntion No.(PIN) - - • • •- ' • -
. "- ' tritth 1;1 e.a.:..4-..;%:'77;:::::::::!:::,1..!:
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Sb;Latitude and longitude in:degrees/minutes/seconds or decimal degreet. . - - - - - • . . DVICtiBOG _ . • :.
(if well field.one lac/lanais sufficient)
22.Certific tion: •
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•Signature of Certified Well Contra - ..,?200
6.Ware)timwell(sigkontanent ,or OTeMporary
, . . . •By signing Ms Arm 1 hereltV certitit that ilk itt://0 was(were).consinwled in accordance
7.:ktlOs i:repr.ir Ilion existing well :Dyes• OrOZ,:o: . - •uith15A,AVAC•02C:0100 or 154 NCAC 02C:.0200.Weli Construction:Standards and that a
.'If this IS a npuln.fill minnow,well 1.011.017frikli!On-Mallon and arplain.11te matte pithy. copyllihis record has been prnrii,d in the urn Owner: • -
repair tinder#21:mark:Section or on the.bae4 of tnisibno. • - .
•23.Site diagram or additional well details:: - - .. .. . . •
• .8:For GeoprObe/DPT Or.Closed Loop GeothermatWeRs having the same You may use the back of this page to provide additional well sito details or well
.construction details..You may elk attach additional pages if necessarY.•
construction.only 1 OW4.is needed.'Indicate TOTAL NUMBER of wells. •
drilled:. • . • . • ••
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SUBMITTAL INSTRUCTIONS..,
••9.Total well depth:below land surface:- 41.00, • •(&) • 24a. For All.Wells: -Submit this form•within 30-days-of completion Of well• .
'Formulttple we/isilit all depths if-different(exasnille-3aii.700.'and 20)1001 - • • •
construction to the following:, • , , •
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.10..Static water level below top of casing:.. CO • • . • Ift.) EthielOn of Water Resoujecee,Information.Procesaing Unit,
trwato-level is cibolie easing,usti-"+" .
. 1617 Mail Service Center,Raleigh,NC:276994617'
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II:Borehole diameter:. • . . • • :(In.) . . . .
24b.-For bilectien WeIls:' in addition-to sending the form-to the address in 24a
.abOve.,-also submit•one copy of this form:within-30 days.of completion-of well
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12,Weii.construerion malted:•Ala'. •_,,tt=. • : • th
.construction toe following .. . -
-ail,auger,rotary;cable,direct push.etc.).•. . • ••
. . • - • .Division of Water.Resources,Underground Injection Control Program,.
:FOR WAltik SUPPLY Vi'ELLS:ONLY:• . .
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. . : •1636:Mail•SeiVice Center,-Raleigh,NC 276994 036-
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13a.Vleict(( pm). 157 . _ . Method.of test: S.:(1.k-4- . - .. 24t.For•Water-Supply gt Iniettion Welk: :in addition to*ending the form to
• • - .the addresS(es).:ahave;also submit one.copy of this form•within 30.days.of•
. .131x.tisinfectien Ince:"frirti. . Amount,).• ' eb Z.•_ • •completion of well•construction to the county health department of the county
where constructed. I
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.Form CW-I. • North Carolina Department of Environmental Quality Division of Water Reseurces• Revised 2-22-2016