GW1--02257_Well Construction - GW1_20240409

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WELL•CONSTRUCTION:RECORD(GW-1) . : ForIntemal Use Only:-
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•1.Well Contractor Information: I ;
:Chris King._ - - ••i4.WATER ZONES I.• • '
Well t°Ontfaeta!NatI1C' FROM' •TO DESCRIPTION 1
ft ft: 11 /
2oso-AU 1 =Vt.- 1'
•ft: - . ft. • . . . E.
NC Well ContractorCertifiication Number .15.OUTER CASING.(for multi-cased wells)OR LINER(If ep licable)•
• Aqua Drill, Inc. . . . FROM . TO' . .DiAMETER1 ' THICKNESS. MATERIAL
it: ft �/ �• /
Company Name 0 l U 3 -• - . 4- . Sid 1z21. �', )•V' 1
. • . 16.INNER CASING OR TUBING(mothering!closed-loop)
•2.Well Construction Permit# . !• I - • • . • -.- . FROM• " -TO: -• DIAMETER: THICKNESS " MATERIAL
'List all applicable Well construction permits(lie.UIC,Couinn•,State;Varlanoe:etc.) . ft,- ft. - I In.
3.Well Use(check Well use)E, - ft.• ft: .in: - - • •
Water.Supply Welly. - 77.SCREEN• . -. - -
FROM- - TO • • . ' .DIAMETER SLOT SIZE - •THICKNESS MATERIAL .
Agricultural QMunicipal/Public - . - .it. : :IL. • In..
Geothermal(Heating/Cooling Supply) ErtResidential Water Supply(single)• ft ft: ln,
Industrial/Commercial . 'DResidcntial Water Supply(shared) 18:GROUT
• Irrigation. FROM- • TO . • . -MATERIAL. EMPLACEMENT.METHOD&AMOUNT
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- -Non-Water Supply Welly: • . -. • • .: • ••0 .:ft' •2t •.'tt.. cle1A.iuc:k'. .•elit'1J5.-
Monitoring [IRecovcry.-" ft. .11.• •
Injection Well:. • ft. • its
Aquifer Recharge • DGroundwaterRemediation tg SAND/GRAVEL-PACK Of applicable).
Aquifer Storage and Recovery 'DSalinityBarrier . -.FROM -.', TO• •MATERIAL -F.MPLACEME'TMETHOD •
Aquifer Test Q Stormwater Drainage •ft. • .ft.
• Experimental Technology '0Subsidence Control•• .. • ft. ft.
Geothennal.(Closed Loop) EiTracer ' • 20.DRILLiNG LOG(attach additional diets If necessary)
Geothermal(Heating/Cooling Return).: tlOther(explain under Remarks) FROM. TO DFSCRIPTION,(color;hardness rolVrock type, in size,etc.)
. 0. .R.'. .4 . 'ft:- •-ICJ i. I; •
4:Date.Well(i)Completed: I q '2`I Well iD# `/
--� . � :ft..• � ft. 5�-ru� .IzQcr. l
Sa;Well.Locationr.- Usti. S.6otY:. . �'U� : T.re.NU e
'\: ..: 1 :ft. ft..
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•FacililylOwne^Name' :FacilityID/i:(ifapplicable) s. ' fh. ; - ::ft, j
1(1 S2 Iz &? (J . 1).W.. • illii.9Ot:► -ram .0 . .ft• ft.. _ !:,i: ` ;
PhysicalfAddriss.City:and Lip ft. R. .
2 REMARKS Ar li Zyjd
County . Parcel-IdentificationNE(PIN) _ tt:w .. 1 y.;z,:r :r; ,L*`:6;s�,if
•Sb:latitude andlongitUde in dagrees/minutesseconds or decimal'degreea:. : - - ' • r`4`+I_~:73' :^- "
Of Well field:one ht/long'is sufficient) : .
V 22.Certifications
• N: . W
6.Is(are)the well(sAtermanent or Temporary
• -Signaaltilc-ofCcnified Well Contractor -Date
Br.signing iliisfirm:I herahv roll&i/sat jibe.nrll(.c)-was(were)ronstntited in accordance '
7:Is,this'a repair to an existing Well:. -DYes. or No. irii/i ISA A'C,1 C 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and thus a
:1jthis:im a-reps it fill out hung;well eonstntrtlan infuarmatirnt and ankh;the nature of the copy njNih record him peen pravldtil to the wr"ll nuvuer.
• repair mule 1121 rentar/reseclian-aron the bad rft/dsform. 23.Site dlagramOf additlDllal well details:
-8:For Gcoprobe/DPT or.Closed-Loop.Geothermal Wells having:the same •You may use the back of this page to provide additional:well site-details:or well.
construcUtin.only 1 OW-1 is needed:Indicate TOTAL NUMBER of wells . 'construction.details. You may also attach additional pages if necessary:
•drilled: •
"r - • SUBMITTAL INSTRUCTIONS
9:Total well depth beloly land surface:" 57 6 J l •(ft.) .24a. For All-Wells:• 'Submit this form within 30 days of'Completion•of well •
. -For nmhip/rr/ls u list ull.deim s/f different(crumple-14200'and 20111101. construction to the following:• -
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.10.Static.water level below.top of casing 40 w -(ft.)- Division of Water Resources,Information Processing•Unit,- •
If water dhowrasing,use"+"" . 1617 Mall Service Center;Raleigh;NC 27699-1617
11.Borehole diameter:• •`Co • -(in.)• • •
-24b.For Infection Wells:••In addition to:sedding the form to the-address in•24a
• ` above,also•submit:one copy of this form within 30 days of completion of well"
12:Well eonstruction•method: ill)a_ 'G�irz Z I 1 construction to the following:
(i.e.auger.rotary,cablc.•direct push,etc.) - •
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• Division of Water Resources;Underground Injection Control Program,
• FOR•WA tLlx SUPPLY WELLS ONLY: ' 1636 Mali Service Center,Raleigh,NC 27699-1636
-13a.YteHd((;pia) ' Z . - . ..Method of test: S lti h• • - •24c.For Water Supple&.Inlectioj Wells: In addition to sending the form to•
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• 'the addresses) above,:also submit.brie'copy•of this form within 30 days•of
• •1!3b,Distn ectlotr?)pe: I4 1 Amount:��Q O Z: - . • completion of:well Construction'to time!county-health'depamnent of the county.
whereconstructed.' ii
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