GW1--01884_Well Construction - GW1_20240322

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'.WELL:CONStRUCTION RIDC 0RD(G0,4). . . . . . . . . .
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,.I.-Forititernal•USe Only: . . .
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•I.Well ContractorInfonnation: •
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Chris King. . . .. .
.. 14:WATER ZONES: .' . ' • •• • : - - . • •
Well Contractor Nanie• FROM .: TO ' • -DESCRIPTION•. . •. . . -
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. 2080A .
. • .76.. f•t.'': •j) ft*: lei ' pi : . . . .
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NC Well Contractor Certification Number •ft. • - • ft " - •• •Y - -
MO; • • 14 1 — '• • 10. .6,.Paill . • - .' - - . . . •' .
, ., •15.-OUTER CASING(for.Ouiltl-essed wells)OR LINER(If a !feeble)- -• •
:ACilia Drill,.Inc.: . • • •V . , FROM., -. ' .TO : ' . . DIAMETER. ' THICKNESS• ' . 'MATERIAL. . • :
Company Name
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' ' . . .. • CI .ft'. .C4-2-ft 6•17g-In.: - .r./g1: ': 64/v
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,.....p,.. • e..—. j: i a. . .,. .Q:.j. • . 16.INNER CASING OR TUBING(geothermal closed-loop)' - . • •
2.Well Construction Peritit#i ' ...-1.7::.7.c......tei....ru ..2 .. • ... FROM . To. . • • DIAMETER- THICKNESS • .MATERIAL . . .
•LIMS!!Opplicabliwell cOnSintetlonpermiht(1.e.WC'County.State.Varlanee,•eta). ' .. -
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•3.Well Use(check well We):•• .
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Water Supply Well • . - . 17.SCREEN : ' . . : . . • . '
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••.. :do Utiohnum. I.. . .•. • . . 'OMunicipal/Publie. ' . .FROM. . •TO. 'DIAMETER 'SLOT SIZE - •THICKNESS MATERIAL :
18 GROUT
..:'FROM'I : ft..:' T 'O. fl'..' . ..111- .. . . . . .. . . _
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MATERIAL ' EMPLACEMENT METHOD St AhlOUNT
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•. Gcothermal-(Hcating/CdolingSimply.) RIR, es.identia.I WatcrSu.Supply(sing.le),
Induitrial/Commercial •DResidential-WaterSupply'(shared)..-. :
Non-Watet Supply,Well " - ' . • if) 'ft.• •leye)•.ft;. 06.tpitilit '. .a1,i ..1.3.
• MOnitoring. . . . . . :• ErAccovery• . ' .' .. ".• . • ..ft.. .." .V .ft. . 1
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.. •• Injection Well • - ' • -.
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Aquifer Recharge : :LiGroundwater Remedietion,• • ft. •.• : - • • . .. .
-A • - . •19.SAND/GRAVEL PACK(Kaoline:Ale). • .
quifer Storage arid Recovery - - EaSalinity Barrier •• .• mom ' .TO . - . ." 'MATERIAL' EMPLACEMENT METHOD" .
' • Aquifer Test - . •OStorniWater Drainage: . • : : .• :ft.: • . . • ft..: . ' • • . .
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• ]Experimental Technology ...OSubsidentaContud 0 ft • . . . .
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. -. Geothermal(Closed Loop) . • • DTracer• - ' • • : •- '20.DRILLING LOG(attach addltianaishietaltineMssar;)..•... -• - . • . ' . : • ..•
FROM . TO • ,DESCRIPTIDN.(colakttardness soil/rock type.pratn•Hr4 etc.).
Geotkennala leMingtool in Retain). .I -lOther(explainimderttil Remarks)
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4 Date Well(s)CampleiediO-44-2`/ Well IDiki- ftft:
..: 6 . ft.:. ,r2cad....e.14 y. .. . • .. .. , . - •. ..
').5—.•. R.• . •- Kid .12.45.r,t. • ,
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.Se.Well Location: • • .
.•• / '''''. ft. 1 q.c.ft.: i 1 )tie . 6iZ1411iik. . • . - . : •
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• Facility:OwnerNitnie . - , .. • .
'feeilny IDIt ofsmilicable). —. - • • -• , ..
.' I r*r,1E,-,..,,,-,..7..,,-.,,.. . ...... . .
JO 76.560i-he e Ai :14; it :5CA'a a 1..Icd• • • . : :..- . . .. IL- '. . ... . ft':- : ' I .. r2.‘C ka.r....i'V.r,_it,,_
Physical Address,City,and Zip : - -ft: • - . 'f0
. . • • • - •MAR 9.
21.-REMARKS I. . . • • " a a
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'County' '.' Parcel Identification NO.(P114) . • - - • - • • r.et. r3Fr.'","....)•'-'?'
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5b,:Latitude and longitude in degreesiminutedgekonds or dechnal degrees: • • . ; • * . . . . . Q/BOG
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(if well field:one latilongis sufflcinnt).
• -- :22..Certifleatipa: '. • ! • . .
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.3.:•.'5/: -..7(at.• •
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.• .. . Signature of Corti ed.Well Coatracrot- ! , : . .
.•Date- . . • -
6.Is(tare)the'well(s)E4ermanent.. .or Diemporary
. .- . • . •• •By'signing this Arm,I.herekeertifj;.ihal the we//(s).was.(were)eonsinteted In accordance
-7.Is ildSla repaL.to an existing Well 'Dyes' or Wo• - will,ISA NC IC OW..pino or 154.NCACO2C:0200 Well Canstraellon.Pandards and.finn a ljthisM'a'repalr,fill out know mit:ell rot:sir:teflon haltratatian and&plain the nature.oithe ' capt eillio record hug been pro tided to the tie!!au;ner• .
repair antler n21 remark%swim Of on the bitchy'this fiirm. ' . • • . . . .
23.Site.diagramoraddithiaal well details:.R .. •. • -
...For Geoprobe/DiT or Closed-Loop Geothermal Wells having the same . You May.use the back of this page'to provide additional well•site'details of well
construction,only I-GW-;1 is needed.indicate TOTAL NUMBER of wells: • 'construction details.-You.may also attach additional:pagee ilnecessary..
•drilled:. . • ,
•-SUBMITTAL INSTRUCTIONS' ! . .
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•9:Totarwoll depth below land Outfade: .. i:(157 • • . • • - •(f*.--)'' 24a:For•All Wells: •Submit this'form:within.30 days'of completion of well'
Fortnitkple wells list all depthe,If tlfljerent(example-301200.'and 44001 Construction to the folleeririg:.
:10..Statie water level below top of casing:- 16 - - • '(ft.) . Division of WitterResources;Inform tin Processing Unit, . • .
fAtiterlet;e1 li ahore mink,use."+:. - .
1617 Mail Service.Center,Raleigh,NC-27699-1617•
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•11.13orelbla.diameter:, • .. (0.-. .(In.) .246.-Foi IniectiOn Wells:' In addition to sending-the Temi..to the address'in 24a
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. . _A 1 _i_., j_......1 I above.also submit one copy Of this form.within 30 days of' completion:of well
• 12:Well-Construction Method:- rt- I 1 L- - CT/11-i' ' - - .construction to the following'
'(i.e.auger.rainy.cable.direct:pa:41.etc.).. ' " .' • ..
• •. - - - • .Division of.Water.Resourcts;Undergtound Injection Control Program,
• : :ForiWA:11.431 SUPPIX.VVELLS:ONLY;• V • . •1636•Mail-Seiviie Center,Raleigh,NC 21699-1636.. . .
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Ali..1:!....la(0,). . .6.' • . Method Of test •.51 q.14 4.. . . ..24c;For Water Suiml i•Talectien Wells: :In addition to sending the form to
, ____.•- • the address(es):above:also:submit one.copy of.this form.within 30•days.of
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13kijisthil•teticu-type:"/4 1711, . -Amount: •/4.• -.U Z. •. •• 'completion of well construction•tol•the county.health department of•the•county
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• -Form GIV71-
• -NOrth Carolina Department of Environmental Quality;.Divisloit of Water ltesoutcwi . Revised 2.42-20I6:
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