GW1--02145_Well Construction - GW1_20240409

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. .WELL CONSTRUCTION RECORD(GW-i1 For:Internal=Use.Only::
1.Well Contractor •
• .Wforaoto=: • . _ .- .
Gary.Thompson 1k WATER zoNES �.a
• FROM. ' .TO DESCRIPTION
- Well Cat:aides NOW: • ' ' it. ft.., E {i • t� • An.441.8-A . .. . - - - • t4 � , cr�k, y ��
:.-NCWell Conteector Certdl ation Number- .. . . .
1S.ODTERCASING(for nulfteeledWats OR LII03R(iris Ms)• _
• Aqua Drill,.Inc . .. FROM ' TO •DIAMETER TES . MATERIAL .
CompaayNeme... . Cto :D. 'E-1 IL h V.. per,
w •
' • : •• : • •_ • L
16.INNER CASINOOR TUBING(vstitermal dae6400p) •
2.'Well Construdion_Permit it: . •3 a
•FROM. .TO'. -DIAMETER•. TH[CI003'S MATERiA
• :List all applicable well eonstr6cliod permit*(Ce.:UIC,County State,,Parlance;eft.) . _' 'ft' '• .1 I°'
. : :3.Well Use(check well use): • • , .. - - . -
. ft Im •
WatekStePPly'We14'_ FROM TO CtIE - DIAMETER 81.01'8I THICKNESS
SIZE MATERIAL•
QAgricultural . . , Q• Mtmicipat/Public; • ft. • :tt.. to. , .
Qtieothennal•(Heatinp/Cooling Supply) '. sidential Water•Supply(fie)- .. • ' - ft:' 'tt " ' in: - " , .
:.QlndustraUCommercial Residential Water Supply(shared)
I iirfngation, • -. - FROM'. TO• . . • •MATERIAL., .. -EMPLACEMENT METHOD a AMOUNT_,.'
Non-Witter Well: •C—� :ft,• • .XO. :tt. :rs.':et6.!:1-a- -:po'4•(r:' .HY('. ..
OMonitoring . . . . , , . . . _ '.QRecovely-.. : . ,. -- . . - . .ft. . . .ft. .•CI 0 . - - • .
Injection Weil:. .
quiferRecharge QamuodwaterRe •mediation . 19.SAND/GRAVEL PACK(Ifapaucable) --
Storage end Recovery • ' •OSaltnityBarner. - • :FROM • -TO .. .MATERIAL. r -ESIPLACE IENrMETHOD'• '
. Agnif r Test .: .:Qstouifliater Drainage •• : . . • I . :
• Ezperimental'Technology• • : _ '. •OSitbsidence Control :
. . Geothennal(CIosedLOop) '. '.Q'Iracer. .- . . 20.-DRiLLiNG LOG(attach addlianll sheets ifnetwoary)-- •
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FROM •TO DESCRIPTION(et'r,hard�e caWreekt ue.arde etee,de.)
: Geothemud(HcathtPlCaoling Rdum) .:�thhtx(explain under#2I Remarks): :�.: •• : ' •.
i.
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. - 4:Date'Wells)Completed:•c. y ' .Well JDi1.. - • .-i a'.f. ieb_ 'i 1 Sums,i" gve I" .
.Sa.Well"Loeatton:' " lib.ft. "• 5. .. : (is ,-,:Cie. • _ . . : . . . • .
•
i 44...i)ck : .�.
FactlitylOwaerNttme 'FaclGtylDk;(ifepPlIcable)" I ..
j • .(6'-( • � a4".a• 'i`#ts:kt': ®,.. (: ,o1 -1'r,,,,e _:-t, h.i. , ;�I tr• ;: • .
R. ft.• •
PhysicalAddress.City�andZiP :
J"G/CCS 31 :Ic.• 1�PR b..w(U
Co arty Patal Ideatiiieation Mo:(PIN) . . . •
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Sb.Latitude and'longitude in degreeslmintiteslsccondsa or decimal degrees . - - r'` " .0 .
(if well field,one W/10.g is 1 of iciept) • 22;'Certifintien • •
.1_,-0, ._ : :
._ : . .. i . - _... : _ _: -.: . i;t: - .- ..
,,_.. .... .. . . . .. .. . 7&::_,-1..-`---1- . • - . .
. •6.['Nye)the well(') Permanent •or••Temporary• , s of used Contttuter :Date . - .
.By*nit*this film,I.hereby cern I,the•tietl(a)was(nein).awistnrctid'in accordance
: 7.Iti thii',repair to an existingwelli.:.QYes, .or: No: " with:ISA NCAC 02C:0100or l3A NCAC,01C:0200 Well Cbn tivctlon Staedaid+:and that a . - :
fthis is a mpatr fllo►tknown well construction brfornmtlon and explain.thenaeve ofthe.- : copyofthlsrecotd has been provided to the nelloivner. .
repair under#21 remaifdsecdonoronthebacc kofthisfam.. • •
23.Site dbtgr'OS or additiona[wellldetalla::
.8.For Geoprobe/DPT.or Qosed--Loop Gcathermal Wells having the same.' _ You may rise the'bade of this pago to provide addiaoaal:well eite.dctaile or well'
' construction,only 1.0W I is needed Indicate.TOTAL NUMBER of wells . .construction details..-You mayalso attach additional pages ifnecessery.
• drilled : : . . AUBM11TAL INSTRUCTIONS} . .
' • 9.•Total well depth belowhind ae face: p ' : ' (1L). i ti.•)nor All Wdlle: :Snlimtt thrs;fotm•within:30•days'of completion'of well
' .:Potmtilliplisivgslstalldepths:tfdlferent(aiotspie-3( 00'and 23,009 commuction tog,NI -•„ +' .
. . 10 Static water level below top of casings._ I®v : (ft.) Divlilon of.Water Reset rcea,Infornidoa Processing Unit,•
-.If wester level is above«uin& :" •1.617 Mall Service(Center,Raleigh,NC 27699-1617
11.Boreholedismeters . -C.` : (in.) • . :241i.Or Injection Well, in addition leo sending tlie.form to the address in.24a. ; •
- .above,also submit"one copy of this form-within 30-days of completion of well
'12.Well construction method: •r.0.B:^ ,"tl�t`r .• . . . . •.00nstrucuori-to.the.following'. . .
• .(i.e,auger,rotary.calAk.ditectpvsli,etc.):_ . .
-Division of Water Resources,,Underground Injection Control Program, .
• .`• FOR WATER SUPPLY WELLS ONLY 1636 Mall Service Center,Ralelgh;NC 27699.1636•
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13a.Yield(gpm) • -t_ Mthod ofte .442' lt,.-1 4-011' . , 24e.For Water Simply do Injection Wellsr In idditton to sending the form to.. . '
' - the, es .:also submit; ne,copy of this form.within. days'of
. • Lib.Disinfection-type •'1'N d "14.... P • ADioD "I b:'1ii•,. comply eioa of well construction to the.county health'•depaRatent of the county,• •
where aoaetencted. .
FonnCOW-1 • - North Carolina Department of Env1mnmentaiQuahty DivWonofWatcrRasourcce -Rcviscd222--2016• . ' .
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