GW1--01952_Well Construction - GW1_20240325

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•WELL.CONSTRUCTION•RECORID(GW-11: .. .FOT InternaLUSe Oilly! .
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'1.Well'Contractor.Informatioir . . . ., . . . . . .
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Chris King • . . . • .14.WATER ZONES• • .1 • . •_ ' .. •. • - - • . • - • '
•Well Contractor FROM•• '-•TO :- . DESCRIPTION- .
well Contractor Name.
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20807A 6-
' . 32:5"L. 3;i0 .t4! iN-1.. . . .- . .
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NC-Well Contractor Certification Number - .' 15.OUTER CASING(for multi-cased went')OR LINER(if do !feeble)
, .Aqua'Drill, InC, • . . . . FROM. • ' •TO . DIAMETER. THICKNESS MATERIAL. . .
- • • • • • • • • n IL: a.?•fi -ft--.6)/V-• I 19 9:- :-..64)1,1
Co an Name '
'..." -Z .."7'Ll .. .16:INNER CASING OR.TUBING(geothermal elosed-Ioop) • • .
2.:WeliConstniction Perinit#: • . .` . 1' 1. . • • ' . • '• •'• • . ,.. :FROM . . 'TO: . • DIAMETER : • THICKNESS• •MATERIAL • • • . .
•List all npftlicahle4ell construction permits(Ie.UIC.County;State,.Varhnice,etd.). '• ' .. . .. ft:. .• ft!..' - . In
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3:Well Use(check well use):. ft In
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• •. •Wider•Supplit Well: . .17:SCREEN .. • .
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. - • -FROM • . -TO. ' - . DIAMETER- 'SLOT SIZE THICKNESS • :MATERIAL
. Agricultural .. 11 Municipal/Public- • • • .. . : • It.. • • ft.: " .in.:
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Geothermal(Heating/Cooling SupPly).IN Residential Water SuPply.(single) •.• . ft... . • •:ft. : • In.
industrial/Commer,ctal. . E3Residential Water Supply(shared) .18 GROUT
• . irrigation . . . . • • . -FROM • .TO• • MATERIAL :.EMPLACEMENT METHOD&AMOUNT
Non-Water Supply-Well:. ' . • . ? •'ft. , i7 - •.ft.' •
Monitoring . . . . EiRecovery.. . . ' • . • . * •ft. • - -ft: • .
Injection:Well:'
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' Aquifer Recharge • •OGrotindivater Remediation - .
: 19.SAND/GRAVEL PACK(if applicable) .
Aquifer Storage and Recovery . : [3Salinity Barrier .. . FROM- - TO - .- . "MATERIAL EMPLACEMENT METHOD : ,
... Aquifer Test- - '.13Stormtvater Drainage - . . •ft•• . • . ft; . . . . • .. . , . .. , . .
, . Experimental Technology •.E3Subaidenee Control . ' ft ft
Geothermal(Closed-Loop)• . DTracer-. .. 20.DRILLING•LOG(attach additionalsheeta If-necessary) - . • . • • . . •
FROM : TO'. . .. DESCRIPTION(colert hardness,ca/rock tee. e.eraIn dm,etc.)
• - Geothermal(Heating/Cooling Return)• 'nOther(explain under#21 Remarks)• •
.2 '1 A 1 I •, 2)0-.ft.•.396. ft.. Blue. •• . rzialiut.-le • - -• . . .
4.Date Weil(s)Complete&...).70S c"+A••I Well ID/i• . ft. - -ft.
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5a.Well-Location: . • - - •ft.• '.
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-Pilat • 771:i014:4A3 Ai . • • • .
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.FacillijeOwner Natio: . . "Facility ID#(if implicabld) • .• •. .' ft. -ft.: :
• • . r7: r.-:.---.c.---.71 .4,c 5 i---•Tv c .‘..g . .. .1.n luch rU, ( :2:7. aa.-.•• -ft...... . .H. - .k.4,„...C....s L'..:'i', r.f f„,":,Li/ •
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Physical Address City and Zip .. . . . . ft.. •ft. - . M AI 'V-iv.: ?JP*
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. - i124:,e.I I. . - . - . . : - - - • , - -•:-
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. '-County- •• "Perce:1 Identifiention No.(PIN) : . : . ' ' -• infccirt;i4iF:n PrrY:,5c4:19,USX . . . . •
- - , CittiQi30(.3 -
• 5h.Latitude and longitude in degrees/minutes/seconds Or decimal.degrees:. ' .-. • " - . - . .:. . .
.(it'will.field.one latflong is sufficient) 22.Certification: - .
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6.Ii(are).theliell(i)6Permanent or.EiTeinporary, • • : -Signature of Certified Well Contra ' •; • -Date • •
. . At-signing Ihls:finma.herehj!call*that thamall(s)ncr(were):con.aralled.in.accordance•
7:Is this'n repair to an existing well: .• Yes. or.EN°. . .with 15,4 Noic 02C.0100.ar ISA NCAC WC.02.00 Well.Con.arnedon Standards and that a
:/Mr Ix a ri.pair,fill put.known well eonsIntel on In entmation and apialti the:nature Ville oilVelisle reirallas beenProrlded to the well imam-
repair jingler#21 remarkv swim or on the hack aPhli farm.- - ' -
''.23.Site.dlagrant or.additional well details: • - -, •
a,For.Geoprigoe/OPT or Closed-LOop Geothermal Wells having the same . .You.may use the back of this page to provide additional well site details'or well
constructitin..only I OW-1 is needed.- Indicate TOTAL NUMBER Of wells • construction details.You may also attach additional pagesif necessary.
drilled: . . .
.. . SUBMITTAL INSTRUCTIONS t • •
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9..Total well.depth below land surface:- _CiL/A • • -...?: .' . 24a.-For All'Wells:: Signait.thi form within'30 days of.crinipletion-of:well
For multiple uriftlisr all depths irdWerent(example-30200'and Ait1001 . -;• MY construction to the following: !
10.Static water level below top of casing: ..sb 6" . • (ft.)- •Division of-Water ResotircescInforination Proaeashig Unit,:limner level Is above raising use"i,"
1617 Mall ServieeCenter;Raleigh;NC 27699-1617
11.Borehole diameter: .6. • •(I6.) . 246.For Injection Wells:•in addition to'sending the form to the:address.in:24a
._,,, A..... ,..n°• i a above,also•submit.one copy-of this form-within 30 days Of completion'of well.
12.'Well Construction method: /:-/•I 14.- .P14 i-11 • - • • .consiraction to the following: 1
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(i.e.auger,rotary,cable, push,etc.). • , I . .
• • • • '•• ‘ DiviSion'of WaterResourees;•Tindergrchind Injection CantrolProgranii
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• FOR WATER•SUPPLY WELLS ONLY: . .' . • . 1636 Mail Service Centel',Raleigh,NC.27694-1636 -
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' -13a.Yield-oin) AO O• -/-7. . -Method.of test: ' 1‘.Cr'h 41-'. : .24c:-For Water Supply&Iniection'Wells:- .In addition.to sending the form to
the address(es)above. also'submit.one copy.of this.fond within 30 days of •
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l3b.Disinfection types ii•1•if- . Amount:• / 'C.,.C.••1 . .: 'completion•of well construction to the county health department of the county
- where-constricted. •
Form C;WA 1 . •
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