GW1--02141_Well Construction - GW1_20240409

WELI;.CONSTRUCTION"RECORD(GV64l) For Inte(nnl Use.onlLT7,77
y
1..Well_Contractor lnfortriation:
Chris:King'
•14.WATER ZONES• " . .I .11 . .
Well Contractor Name FROM . TO -DESCRIPTION
2080-A_ • :416 .ddol.. .R. 1...6 i''1 .1 pl
• 'NC.WeIIContractorCertifcation Number. . i
iS:OUTERCASiNG(for multi cased'welb)OR LINER(If.to, licabie)
Aqua'Drill,Inc FROM TO DIAMETER THICKNESS MATERIAL' "
:Company A'ame• • • •O:n.: ft: / is
i I� C� 7 '16.INNER CASING OR TUBING(geothermal c1osed:loop)
2.Well Construction Permit#:`)(J"I ! .J . FROM'. TO DIAMETER . THICKNESS' MATERIAL
List all applicable cell construction permits(I e.UIC,Conntr:State,Variance,ate.) ft.• fL. I I •In., •
.3.Well Use(check'well use);' tt.. . n ;' In.
Water Supply Well: • • • 17.SCREEN.T13..,
•
_ .
• Agricultural.. FROM. TO• .' •DIAMETER I SLOT SIZE . •THICKNESS ' .MATERIAL
. �MUnicipaUPublic it: •R,' : • in.
Geothermal(Heating/CoolingSupply) "{ Residential"WaterSupply"(single)
ft: it.. In.
Industrial/Commercial QRcsidcntial Water Supply(shared)"
" Irrigation. 18:GROUT .:
FROM. TO - MATERIAL . 'EMPLACEMENT METHOD&AMOUNT
Non-Water Supply'Well: Q at.• : X 0 R: ,� . �
Monitoring: . DRecovory,., R:. ��r'r �l{ .. �s11�.�.
injection Well:-
R.
A" tfer'Reclia a .
.QGrouridwater Remediation-
Aquifer Storage and Recovery .19;SAND/GRAVEL PACK(if applicable) -
. QSalinity Battier .FROM • . TO- • •MATERIAL. -:EMPLACEMENT METHOD
Aquifer Test QStorinwaterDrainage ' . " ft•. , ft.• - i
Experimental Technology; : QSubsidence Control .ft. . -n.• - ! -
Georhennal"(Closed Loop) •DTracer • 20:DRILLING LOG(attach additional sheets if necessary)' ' " '
Geothermal(Heating/Cooling Return). f l'�'(iOther(explain under'#21 Remarks) v 7CJ FROM . To : : .DPscRIPTioN motor,tisrdnest.sell/rock type.,ram size.etc.).'. '
ft:: tt..C_' y
4."Date"Well(s)Completed:3:-2..S"a I. Well lD# ft. ft, i :
So:Well Location:. - _76 ft." io ft. ..611,1e.. •6TZia)tl'aje
00 y 'PEA:4.2ga,�ss• •ft:. . It. I
Facility/DU/nor (
Nnmo " / I• 1 11 1 N ifswppllcablc) ft.• ft.' I' :gaga,. v . "i i .
is ) �rim.I �� �'"4 !_rr_.; io 1._ �_
,r'riv etzclii.Ass lw. c +t•:: :fl: t f�
V'
Physicaall�Addn.ns:City:andZip ft: : ft. : APR .eT Ltv24 -
•
County' PateclIdentificationNo,(PIN) DVvu....Y..J(:.- _
5b.l.atltude•and longitude In degrees/minutes/seconds or decimal degrees ' ' "
•(if well field,one laUtong ii sufficient) 22.Certification:
• '6:Is(a ar re)thewell(s)eFmanent or•.Temporary. Signature ofCenifi Well C nttacter ; .Date
• .By signing.this,iiii s, I hereby ienU,'ilia(the.nell(v),iins(were)canstritrted in accordance' •
'7.is this a rcptI_h to an exliting well:. Dyes "or.:No • with ISA-A'CAC 02C:0100 or•ISA NCACi 02C'.0200 JVell Conslrueilun Slanrtath and than a
(Phis Ls a repair,fill an,kniina will innetnn'lion Infinmallon and erplalwlhe nature alike 'ca/ti:of tills record has'heen prnvldisllo the ircllhivne,
repaii under h21 renrarhe ceriumn or"on the bath nflhis form. "
23.Site diagram or additional well details:
8.For"Geoprobc/DPT or Closed-Loop Geothermal.Wells having the creme You may-use the back of this page to provide additional:well site details"or well
constntctioa.only1 GW-I is needed. Indicate TOTAL NUMBER of wells - .constniction details. You mayelso;attachadditional pages ifnecessary:.
'drilled
r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:. J" .0 S • . '
• .For nndrIple wells list all depths ifdfercnl lesaniplc-'3 200'and2@000ry (ft) "construct Alt thef l wing'Subm: this"form within 30 days of completion.of well
• construction to the following:
10.Static water level below top of.casing: ' • C.''.v .
(ft.) vision Of-Water Resoirices,:Information,Processin unit,
,.•If uoter.lerel Ls above casing:use•#"
1617 Mail Service Centeri.Raleigh;.NC 27699-1617.
11.Borehole diameter: (in,). I j j
24b.For infection Wells::In-addition.to sending the form to:the address in'24a
,^ s" above:also-submit one copy of this:!form within 30:days"of completion of well"
12.Well construction•method:."r-f:u i'Z ..RI '1 I.•" construction to the following:.(i.e,auger.rotary.cable:direct push,etc.).
- "Division of Water Resources,.Underground 7njectton Control,Program,:FOR iVA a L'?"SLPPL�'WELLS 01'iLYe
1636 Mail Service Center,Raleigh,NC'27699-1636
1 II
gp ) . " Method of test:- I irk 7- 24e..For Water.Supply Sc'Infection Weller In addition to sending the form'to--
�" the"addresses) Above,'also submit''one codays
• 13b.Dfsin;uctian )1oc: I4 T f, py'he this"form within 30 of
Amount:140 -�: :completion:of well construction tO"the county health"depamrient'of the county,
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resource-¢' v-.:::gaol o.r,r11<
1 ;