GW1--01602_Well Construction - GW1_20240308

. . .WELL CONSTRUCTION.11tECORD:(GW4) . . ..
• •For Internal Use Only: . . .
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1.Well Contractor Information:
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Chris King - 1. .
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14.WATER ZONES . .•
Well Contractor Name .FROM. • .TO _DESCRIPTION
2080-A • -ft. • - • ft.. • .
. '•' ji,ed. . • 0 .. .-7 , • - 7: . ,•
" I." • ft, . I
NC Well Contractor Certification keen:. t
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A 15.OUTER CASING(for IMO-cased Wells)OR LINER(If applicable)- •
qua bri k Inc,
•FROM. • TO. .. 'DIAMETER THICKNESS • -.1 MATERIAL - -
.Cornpany.Nante • . . 0' I.L.,11.0;a.."..-16 A. '''.. ,o/g . -' 6,44, .• . •
e.....cr• L 1
• •16:INNER CASING OR TUBING(geothennal chised-loop) - • •. • . . . •. •, - .
2.Well-Construction Permit&F:.. ••• •D..-! .,10.eLiKi 2,13. . 'FROM. TO' .DIAMETER• . THICKNESS' . MATERIAL . • -_
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List all applicable me construction perniits'ae..111C.(Annoy,State.Variance.-etc.)- ft.. : • .11: • . - in.-
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3.Well Use(Checkwell use).:• ft. '•ft. •= n. . .
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. :Water Supply Well • • • •17.SCREEN"- • . .' . .' .. • -. •FROM - - 70' ' DIAMETER • SLOT SIZE .THICKNESS'. 'LVIATERIAL
Agricultural -0Miniicipal/liublic
•it. . :ft. • - -In.•• Geothermal(Heating/Cooling:Supply) .2fitesidential•Water Supply(single) ' . rt.: . • II"; .- in',. .. - - ' .- .- -" . - : . . • .
.• Industrial/Cornmercial .-DResidential Water Supply(shared)-• •18.GROUT • • - . . .
• •
• • Irrigations , .
• FROM- •TO ' . • °MATERIAL- . • EMPLACEMENT METHOD&AMOUNT
•• NDIILWOOTSHppliWell: . - ' •
. ' .• O.:.11'.• (:):':i'L.:1.5efi46;;k
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Menitoring: . . . Ditecovery .
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Injection Well:.
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IL" :ft,: . ' . - •
'A quifer.Realialge, ".'Lletoundwar'Remediation
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. '119.SAND/GRAVEL PACK(if applicable)• . - • . • • • ..• _.
:.• Aquifer Storageand'Recovery .r3Salinity Barrier
• FROM. • TO " ' : °MATERIAL:,. . . EMPEACENIENT METHOIL! ' ••
Aquifer Test '.0Stormwiter Drainage• • .ft. .I - ft, • -
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' .. Experimental Technology -,DSubsidence'tontrol • . R:. ' . . .• . •
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Creothennhl(Closed Loop)- .•DTracer 20.DRILLING LOG(attach addltionalsheetti if necessary)•. - • . . . • .' TO.• • •DESCRIPTION(rotor,hardness,saWrock type,grain size,etc.)
, tieothennal(Heating/Cooling Return) -fr:TIOther(explain under//21:licinarks): :FROM.
- - 0 ft.:- •-6-. t6. Red . .cloy. . .4..DEte.Well(s).Completed:2. 2 ) .2$ell mg.".- - '
•
• ':e) .ft--)66" '"' 5i/iV 4 .:r&CI.- PI U e .,
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Si.Well Location: ' -ft'. i litcft;-.-8/(. -CC---•c-64741- );44'4"r-'''•••• - - . .
ft.: '. • ft: ' - i rid.--Le.C...1 V E.L'i -
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-- , -
ft.. 'It. • •
kicilitylOn wor Name ,•Facility,1134(if applicable . MA R S 241). •
0 ,20. . . • .. .
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).,46s__ oodb.ittoK. :Pit ...66itifiNici tut):'iv,e:. ft.: - :ft.%
. '.Physical Address.City.and
ft ft ' Intozr caul P rtt.r.,504*.r.1
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-• DWC,':0,-..7- - •
MOM'NU Ce . . 21.-REMARKS
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county
.Parcel Idnntification No:(PIN) • . :• • • . . .. .
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Sb.I.atitude and:longitude in.degrees/minotea/seconds.or decline!degrees: . • - •. • . - . .
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(if well ficld..onclalilong iS sufficient).
22.:Certifica on:. - •
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Signature of Certified Well Con ctor ; . batd
6;Is(ain)the well(s)Aormanent •or Oteniporary
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•Es:!iening(kik fink I kareky eartffY•that du;null(r)was(Wire)eakstnteled in aordan,.e
7.Is this n reptiito an existing well:- 'Dyes ori 12(41. o With 15A.AV.IC 02C.0100 or 154 NCAC 02C:0200.Fi'en Conetraolon Standar&and that a
Okra!ilitc reeind hos ken proilded to the Well owner.
11thk la rmair.:1111.0111 known'it,.!!eansaltellon!divination and evloin'ha nature tuft!,,.
repair under 521 mimics;vedian or on.the.huek ofibis jinn: .
23.Site diagram or additional well details:- •
8 For Geoprohe/DPT Or'Closed-Loop Geothermal Wells having the same. You may use the back of this page to provide additional.well site details.or well
: •
construction&Mile:-You May also attach additional pages if necessary..
.construction:only I.OW-1 is needed: Indicate.TC)TAL NUMBER of wells
chilled: . .
SUBMITTAL INSTRUCTIONS
A </' -7..".9.Total well depth-below land surfaCet • i:.0 j . • . - (ft) 24a:Yor•Alt Wells: •Submit this-form within.30 days.of•comPletiOn.of well
For MIlkirle wells list all&wilts lidtflivent(example-3kii200'and 2010(Y) construction Mthe following:-
10.Static water level below top of easing:. .C-6 . (ft.) Division of Water Resdurces,Inforination-Proces:shigDniti
If taller lore!is above easing,use"+"
1617 Mall ServiCe-Center,Raleigh',NC 27699-1617
.11.Borehole diameter:. . 6 •(in.) 246.For infection:Wells: hiaddition to sending the fOrm to the address in•24a
above,also submit one copy of this fOrm:within:30 days of completion of Well- .
II WelFeonstrectiOn method: A it'? .r)RI•.j.1 - constructian to the following:
(i.c..augcr.ratary,cable.dircctpush.etc.)
• • Division of Water Resources;Underground Injection Control Trogram,FOR-Wil.T.ER SUPPLY WELLS ONLY: . 1636-MallServIce Center,1Ralelgb,NC 27699-1636
I •
.:13a.%:!cid.(gpni.)- .2.0. , .method:of test:D i C1 li:f 24c:For Water Stien6&Infection Wells: -In•iddition to sending the foil?'to.
.the addre§a(es):above.-also-submitl one"copy:of this form Within.30-days"of
13b.-DIsiUfectica--47.3c: frirti. .Aiftoufte-)4 .67- 'completion of well construction to the county health department of the county
I Where constructed.,
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Form DW-I. 'North Carolina Department of Environmental Quality-Division of Water Resources Revised/-22-20 I 6