GW1--01886_Well Construction - GW1_20240322

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• WELL CONSTRUCTION liECORD.(GW-1) : • . . For Internal Use Only:. . . . . ' - •
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1..Welltontractor Information: . • .
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•:Chris King' - •- . - . . . . . . . . : . i : .14.-WATER ZONES'. . -- : ' 1. . • - • . . .
• • •• FROM ' TO, • DESCRIPTION.' - ' ' . •
Well.COntreetor Ntime .
1-k1-.11.-...',I I. .ft,..•- CI• -4-i•P)•m•• . . •
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:2080-A. • • • . . . . : - •ft. : • ' '.ft..:• - 1 , . - .‘ : : • •
' NC Well'ContractorCenitiention Number ' ' . . .. ..13.•OUTER CASING(for multi-cased wells)ORLINER(if ap !feeble). • •
• Aqua.Di18,-Inc.- . . . "FROM- . . ' •TO . . '. DIAMETER ' THICKNESS- • MATERIAL . • . ,
' •"Corn any Name : • . . •0 -Ito • .42.ft.• .8/g. 111 ". I ! ‘ • oi)iv
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.......- 3 16.1NNERCASING OR TUBING(geotberntsl•closed4o0) ! .. •
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.2.Weil•Cmistruttion Permitli: D (1.5.3 6)C"i.AI 2. . . : .. . . .FROM '.' TO . . . 'DIAMETER' :THICKNESS. _ 'MATERIAL' .. • ' •
List all applicahlentlIcaaaiitcfian permits* :e.:CIL:Como%Stale.Vdrlance.ea..1: • • ': ::ft''• : 'It
• . 3.•Well•Use(cheekWell use):. . • . . . . . .
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r - . •17.SCREEN • . • ' • • ' • . • • • •• • . • . •
Water SupplY.Well:- .. " FROM ' .TO .: -.DIAMETER'. SLOT SIZE THICKNESS • MATERIAL .
- "Agricultural .DiMuninifial/Ptiblia. - . • ft.- •. - ft.• • .1n.• •• • • • • • • .
Geothermal(Heating/Cooling Supply) :121thtidential Water Supply(single) • . ft:.: . • • •it:. *. • :i„;. .. . • . . •
•111.iticlustrial/Conupercial :0 kcsidential Water Supply(shared).... r:18.GROUP. .. '- '-. . ' • • • • • .• .
•••irrinaticin . .. . . . . .. , .. . •FROM"_ TO'. ' • MATERIAL . -__ EMPLACEMENT METHOD&AMOUNT.
Non-Water Supply Well:- •
• ' ' • ..6. •m. .):(5 .ft'.- g4Aiik. . -/A;15.5-
• -"Monitoring .. .. .•ORecovery ft • .
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InfectiOn•Well: . • . • ft. •ft.. •. • . .
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•a Aquifer Recharge.. .- IDGroundwater RentediatiOn• . • ' ' ... . ' • • .
• '19.SAND/GRAVEL PACK(If applicable) - • *
111)Aquifei Storage aridRecovery • .OSalinitS1 Barrier • . .. FROM' TO • _MATERIAL. - EMPIACEMENT METHOD • ,
Aquifer Test. 1:IStormyrdtcr Drainage'. • . . . . •
- ilt Bxpeiimentattechnolegy. . . DSUbsidence Control ft ft • '
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.Geothenual(Closed LOop) • ••0)Tracer- .. ', . .' s,., . . - 20.DRILLING LOG(attath additional sheets If necessary) •• • ' •
: - • .FROM- - TO- - - - DESCRIPTION(color,bentnesLlatUrock type,grain stze,vte.) -
Geethermal Illeating/Coolingitetum) • riOther(eiNainiandeilt21 Remarks). • - • •3• I
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• • •6,• 'L. . ] •L '.ike d IP V. - . . • . . . _ ..: .. . ' •
4.Date Well(s)Completed:3.-9.-2 •). Well ID#.•• • • . " 3 .'. ../5-'. ft.' .5 A.iud• •12:4-c-IC .. ' . •
• . - 511.Welf.Loatation:•.-' . • ' •• •• - ).5 - 72S-h.'. 1310C. 47.6iNt4C • . ..
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EticilitylONVIr2i Ithtm6 . - • .Facility lEtti(if epplidahlc). ft ft
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)626 :-.5:fle.i4:h efik.). 1414 h•••5c:ke 61 '.1"tcj: .. - .:• • • •:ft: . •ft -• • n,,,,,,, . 1,-,..,..
•- .i.,---e 1 1 es .` .
: • :• • : : • Th.N.....%:,..•.-8.:....ii-.4• ..;,,, • . • • . •
• Physical Address,City;and Zip. •
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' •.lrok - - . 2'REmARKs•• • . - . •. V.A.R 1 ?. 2021 _ .. ' . :' :. -
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.ceurity, . • Parcel Identification Nd:(PIN). • - - - - - • - - - - - - • •
. - infpriri,94 a PrWk1:2 LIM .
.Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:- - * . . r ' C.,;3..,-.13:2•
.(ifwcll ficId.-one'lat/Iong is sufficient). • .
:22,-Certificationt . I
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.6.1s(are)the well(sackermanent or:latemporary - • , . 'Signature of Certified Well Con ,tor , • . .Date • -
' .By-signing ilds:kin,'hereby eeriffitha1 the well(s)wds(were)emisIrtuded in•aceordance
7.Tanis u repast to an existing well:. Otis.. or EILNo- •",: •with MA 1alC.702C.0100 ar'154NCAC 02C:0200 Well•Cansinnalan Pandairfr and theta
•MIA'Is a Ivan;J111 not kinnwi.well camorindion Information and esplaln•thcrnalore aline . a61,.r oft/ifs earned has heal,P.mrldad In the urn
•repair antler n21:refnaeks sedlan ar'on the hark nflIdsfin7n. •
• • -•23:Site diagram or additional Well details:
•8..FOiGeoprotie/RPT or Closed-Locip.Geotherniat Wells having the seine . - ' You may:use the back of this page to provide additional Well site details or well
constrUctiOn.only1:1.041.is needed:.Indicate TOTAL NUMBER of Wells -construction details. You may also attach•additional pages if necessary.
•drilled:• - ' -• - ` . - ' •St/BMiTTAL MllTRI/CT1ONS' ' .
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et (
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• 0.Tao:twat!'depth below land surface:. ... .2 n .,*. . . • ft..
)• '24a.,For All Wills:.Submit-this form within- 30'clays of completion•of•well
Fat main,*Wells list all depths Ifdlointni(example-30200'am1•20100') - .. ' 'constniction to the following: •
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.10.Static water level below tOp.of casing: - ,,2•0 • • : • (ft.). :Division of Water Resources,Information Procesilng Unit;
•limy,.lerel is above easing.use"+".. 1617 Mail Servlee Center,Raleigh,Ne.27699,1617• •
II.Borehole'dila:meter: • - • - ;(I...) . 24b.For Infection Wells:•In addition to sending the form to the address in 24a
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.*above,also submit one copy of this form.within.30 days of completion of Well.
12.Well construction Method::• :14:ilt .C/Z': 1 I . ... . .i. . construction to the followieg: •
(i.e.auger.rotary..cable.dircct.push.etc.) -' • .
. . • . . ., . . . . .Division of Water Resources,Underground Injection Control Program,
• '.FOR Wica,Ela.SUPPLY WELLS ONLY: • .
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1636 Mall Serv1c4 Center,Raleigh;NC.2769946.36.
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13a.%laid(npui)• 4 -. • :Method of test i-5.1(1 it.f. . . - •24e,For Water-Sum*8rinlectioti Wells: In addition to sending• the form to.
. the.addiuts(es)%aboVe, also submit brie.copy-Of this form.within.30'days.of••
. .. 13b.Disheectian.t)Te: .) • . AMoOnt:.i.'6- :.1)...±-.1% .
,ir.H.- • completion of well'construction•to the•county health..detsitment of the.county,
. • ': •; • " .Where:consirticted.:
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'Form GkV-I- • . • -•Nortli Caroline Department of Environmental Quality-.Division otWater-Resotuces'. •, - . •• • Revised 2-22-20 Id
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