GW1--01885_Well Construction - GW1_20240322

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•WELL-CONgTRUCTION iflIt6ORD(GW4) For Internal'Use Duly: • . .
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I.Well Contractor Information:
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Chris King. .
. . . . , .. . . ..14.WATER ZONES . .. • i ' - "
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Well Centrector Nellie •FROM •TO. • •DESCRIPTION.. . .- • - •.
108.0-A
I 7.41Y' 17/ -ft' 1,5".'6,12vkig. . . . . .
• ft.- . .. ft: . :.
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NC Well Contractor Certification Ntiniber •
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IS:OUTER CASING(for mtild-cased wells)OR LINER(if ap !Cable). - . . •
Aqua. nil,.Inc: - . FROM . TO. . . DIAMETER - .. •THICKNESS '.•• MATERIAL.... .•_ .
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ComPanyName •
O. • ft.. .44. 'ft... 16 flk,..in. SaNgrt ' $9 6glii
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• . 16.INNER CASING OR TUBING(geothermol dosed-looto). ' •
2.Well consfraction peiiiiltm:.cti 7.6,./.,.,erk iv-2.ci• FROM. . TO ' • DIAMETER'. - THICKNESS -• MATERIAL
Lisral i apidirahle mil eanktrucrlan permits(i.e.WC.Conant Sraie.VarianCe.,ere.)'
3.Well Use well use): • •ft.• . .ft. - • 1n.- . .
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Water Supply Well: . •
• 17.SCREEN .: • • • •
' FROM Agricultural E3Municipal/Public ..: .TO •DIAMETER. SLAT SIZE . -THICKNESS . MATERIAL . .
. • • 'ft . ' •ft.
Geothermal(Heating/Cooling Supply) • caidential'Water Supply(single) '. • ft; •. •R.'.. In.
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.. Industrial/Commercial' • Residcfitial•Water Supply(shared) •• • 18.GROUT.. . • .• :- • • • • ' ' . •-.• . • • ; :• •
-.. • Irrigation'.
FROM' •TO . • MATERIAL, • - .EMPLACEME.NT METHOD&ANIOLINT.
Non-Water Supply Well: .: a• It'. C).:ft..:geialLti. ;°*. ' -diiiir r:
horiitorftigs . .Oftecavery..
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• .Injection Well:• •
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Aquifer Recharge ' nOrpandwater Reniediation " . .
•19..SAND/GRA (ff OpplIcable).'. • . . ' '.
... Aquifer Storage and Recovery USalinity Barrier VEL PACK
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- FROM• • TO . :MATERIAL. . . ' EMPIACENIF.NT METHOD. • '
Aquifer Test .EIStormuter Drainage ft. ., ft• •
. . . .Experimental Technology .QSubsidence Control • .
- •ft.: • : : :fit, . .• . . •, .
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geothemm)(Closed Loop) . .0Traeer • .20.DRILLING LOG'(athich addithnuilsheetslf necessary) . • •
' 3. ft.. • ...ft.. < d • red le . • ••
'D FSCR LvrioN. (color. herd. ac ess.solVrack We.ilsniu size,etc.). . .•
- .'.•.Geothermal(Heating/Cooling Return). "1710ther(explain under#21.Remarks): •FROM ' T° •: . •. . . . n fis. : :3. •ft.: .-5o 1 i . . • .
'3-.7- 79.
4.Date•Well(a)cornpleted: - - , • •Well 1D# • . . . . . .
... .Se.Well Location: )5-- fr.' 65.."'... .1- i ti e•. oir otalv1,4 . . . .
. ft.. . : ft.
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Foci Illyi0WIltr Name. - Facil ity.ID/4(if implicabie)- 1.1.• . It. ' '. '
‘:. . .ft.. . . :ft... 117..7t‘L7.77.C.:1.77..... .141-if irr;....,. ..L.04--)
i)t..aft l'er c•-6.-Vohi e. . o rt .
. •phy:.iiccilAdtlics-s.'City,Mil ZiP •
.f.;4"17--1.:() . R.' : ft: :
21.-REMARICS. . . - .. • . . MAN 2
- .2 7074 •
ligilligiv:c-P. . ..
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County • Parcel Identification No:(PIN) - • • . . Int:;,-ina;in prrx...Nw.sgrig,ux/4
Sh.'Latitude and longitude in degreedminutes/setonds or decimal degrees: • . ' • • .• '
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(if well tlekkono lat/lorig is sufficicna.
22.;Certifiesi n: •. .
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' •1.7J-1: . • ...4''2*2(./.. .
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6.Is(ore)the Well(stakerinanent or.E3Temporary. Signature of Cettificd Well ontrac ;- ' lirte
E(i signing ildr Ana 1.1ierehy rerryj thin.the nt://(s)war.(were).ennstrarred In deenidunce
7.Is this a repti:?•ta an existing well •Dyes or-ONO with 154 NCAC 02C.:0100 or ISA NCAC MC.0200 Well Cnnninnedan.SiandanIn and dun a
II:MINA wry:pair,fill out banal Well ronstriredan infirm:ohm and explain the Amore of the .may(Olds racord has been provided la the well owner.
repair trader tr21 pentads section ar on:the bark of this Pm.
23.Site diagram-or additional Well details:
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For Geoprobe/DPT or Closed 40p GeothermalVellsbaving the same
.You may use the back of this page to provide additional well site details or well
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consnuction:only I GW-I is•ncecled. Indicate TOTAI.NUMBER Of Wells construction details.'You may also attach additional pages if necessary:
drilled: .
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$UBMITTAL INSTRUCTIONS.
0) A,..----
9.Total well depth'below landsurface: . 4‘,/. . - 1114 24a.•For All Wells: '.Submit this form Within-30 days of completion of well•
Forntultiple wells lisr all depilri rdigerent laransple 30200'and 201001 construction to the following:
10.Static water level below top of:easing: 3 0. (ft.) Division of Water Resources,Information'Procesaing,Unit;
/Auger kid Is ahem easing,use"4."
i 617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: . '6- . .•(in.) 24b.For Inlection,Wells:.In.addition to sending the form to the address in 24a
.s • 0. „: .
12.Wellconstrtietion method:..A.:)17. - • i II- .. above,'elk)submit.one copy of this form'within•30 days of completion of well
construction to the'folloWing: • • '(i.e.auger.nanny,collie,direct pusk etc.) I
. . • Division of Water Resources,Underground Injection Control Program,.
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FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,ROleIghiNC.276994636
13a.7,-;,eld(gm) . .- . .Method of test:.S•i:•:9.h+ . . 24c.For Water'Simply&inleetion•Wells: •In:eddition to sending the form to
• tbe 1 : litrlint type:. '/4.' _ Amount:.-el‘. .6 Z.. •
3b DIs rit • •the address(es)'above..also'submit brie.copy-of this form Within.•30 days of
. 'completion:of well construction te the county'health department of the county.
,
• •where constructed.
Fonn GW-I ,North Carolina Department of Environmental Quality-DiVision of Water Resouireg Reiised 2-7.2.7.ni6