GW1--02258_Well Construction - GW1_20240409

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WELL'CON.STRUCTIONAECORD. GW 1 . . •
. For Internal Use Only: . . . .
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.1;Well Contractor Information:
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Chris:King.. '..
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•- , • • •I4.WATER ZONES • • .. 1 1• . .• . . . . .
. .Well Contractor it .. • FROM ',: •TO, . - . DESCRIPTION . : -
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2080-A:' • . • . ' ..'39'61. 39 ( ":- : .5741Pi.pi- . - •-
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'NC Well Contractor Certification Number: • .• .
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' . IS.OUTER CASING(for mul(kased.wells)ORLINER(if ap cable).
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Aqua Drill,Inc.. • . - •FROM• - - ,TO. -.: , DIAMETER'. : I.THICKNESS. : MATERIAL
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- . '' (:)•I:I. .1.'10:11* .6..Yq. ,!... SPR21 ..f rW•t•C•-•.
.. . .16..INNER.CASING OR TUBING(geothermatclosed-lotin) . - . •
2.Well ConstinctiOn'Permit#: .3 :I-,L):. : . - -'. . . . ,FROM. ' TO. _ - .- •DIAMETER. • 'THICKNESS ' • MATERIAL .• - '
list all applicahle:iirlliwidireclion.permiti(I.e..ille.County.State.Varianre.ere.) ftn,- ' : In.
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1 Well Use(check well use): • • • • ft: •R.• Io.-• • • • '
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. . Water Supply Well: ' . • 17.SCREEN .. . .
. • •FROM-. • .TO- . DIAMETER : N.:01,mm.. TmacNess : MATERIAL . . :. ..
Agricultural: • .1311.eltmielpaYPtiblio. ft.: . ft.: " In.
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• . Geothermal(Heating/Coaling Supply)"alleSidential Water SuPply(single).". ' ..rt.• : .In.
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Indtistriakoinmercial: DResidential Water Supply(shared)..'
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' •• . Irrigation - - . i FROM : -. TO . '. 'MATERIAL: _. 'EMPLACEMENT METHOD&ARIOUNT
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Non-Water Supply Well: • . • ..0-- It :20.: 'ft* " 3i7t14.110C .- -61i-p<'
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• . - Monitoring . . . • ., .- Ukccov.ery. - - - . . . . tf.. .
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• .Injection Well:
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Aquifer Recharge . : EaGroundWiner.ltemediatioti - .
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• •I9..SAND/GRAVEL PACK(If applicable)• . . ..
: .Aquifer Storage and Recovery- -DSalinity•Barrier.• ... , • FROM .• ,TO • MATERIAL . ' - •EMPLACEMENT METHOD
• Atniifer Test: ' ' ..:E3Stormwater.Dniinage. • .
4.• ft. .
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• .. • Experimental Technology. 0Subsidence Control• • • ' • ' . tt. ' • •ft..- : 1 " . •.• . • .' . " . . .•
.". Geothermal(Closed Loop). • • • E1Tracer. ' •• ' - - 20:DRILLING LOG(attach additional sheets If necessary): °. : : ' . ' .. . " •
OM ' - 'TO• - • DFSCRI PTION(color,hardness,.solUrock type,grain thr,ere.)
- • Geothermal(Heating/Cooling Return). . rrlOther(explain under#21 Remarks) FROM
CY ft.;. -.•(°.... ft....•..i?et.d.,' .e. isv-y. . •
.1 CI• . .• • •4:.Date•Well(s)Completed;9 -. .La. ..--, t Well ID#. . • • . • • • - .
. *6 It• ' 16.s7n...S.Arad:-.1.26 c
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Sz.Well La-cation:. ,' . .
' 1657.ft•- •<46$7.' :Ricic',•6,1zielfri.:71'e. . . .
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.. • As ' .v !Faclity:OwnerName Facility DU(ifaplienble)175doiiRd PciAp i ‹. ft
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Physical Address,;City,and Zip' ft
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..e.A.S.G.ie.1 1.• • . . .. • . . . •••
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• . - ! " " .4 f'ff II.Ai''2091 • • •.. , .. _ ,_ . . • .
County: • . •
.; •Parcel Idetitificition'No.(PIN)• : "'• •• • •• • .
. - . pii-ci;i•r;:,:;x.n
- .51.taiitudeond longitude in deo'eeshithiutes/secorida or decimal'degrees:. • .- • • • • • . • 17'V`I'7`../.!:
:(if well field.one lationg is sufficient)'
22.Certifle 'on:.
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. 6.-Is(arc)the nvIl(sPernianent- oi131Temptirary • 'Signature of Ccrtific Will Contractor ".' Date'
......„. , :By signingilds.finvn,"I herehy.reeitA,ilaiiilleivell(s)war OrerW'ionsiint4eil In'amarilanee •
7.Is this a'repair to existing well • Dyes Or 1?.M...Alp • • with/II A'C'AC 02C.0100 or ISA NCAC 02e.0200lVell Coninvicilen Siandarthi and that a.
. •If Ale I.v a repair,fill ouihnonn•leell cansintilinn lolhimaihni and e..rplalo:ilie nature a f the. 'ev.,111,ni ill&ret.(01 has been.Prmided in ihe.ne(ATLI'.-
repair under 11211empiliS Milan or on ihe hark alibis form,
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. . •23.Site diagram or.additiOnal*ell details: -
• 8.For cooprobomPT or,Closed Loop Geothermal Willi.having thesame You may use the back of this page to provide additional well site details or wells.
construttion.only I GW4.is needed.:Indicate TOTAL NUMBER of wells- • • :construction details: You may also attach additional pages if necessary.
-drilled: . - .
•SUBMITTAL INSTILUCTIOrilS• i r
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-9.Total well depth below land Surfae '.e:- -• U.L., .. . •
- . Ift4 24a: For•All Wells: :Submit this:font: Within-30 days:of completion of well:
For nntliiple..vcdis list all flepthsifdIfferent(dem*.302007 and 200001: •
•construction to the f011owing:. -
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10:Stade-water level below.63a of casing: • • • • " • I%) - Division of Witter Resourees,!Infennation ProtesaIng Unit,. •
if water leiyd Is uhave casing,ose.."t" . .
1617 Mall Service Center,Raleigh,NC 27699-1617-
IL Borehole dlametei: . •• 6- (10 .
241);Far Ifilection Wells: In addition:te sending-the'.fOrm.te the irddresa.irt a-
•ahove.also submit one copy of.thia•form-within.30.-days•Of completion•of well
.12.Well construction method: 'A IR.. d:al I I... . .. . construct to the following: -
(i.e.auger;rotary,cable,direct push,etc.) . • . .
• . • • " ' • . Division-of Water Resouties,Under.grotiild Injection-Control Program,
• FOR.WATER SIIPPLY.* . •ELLS ONLY • . .
. 163.6.Mail Service Cente4.Ralelgb,INC 27699-1636
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.13a.'Yield(gpra) - : • • • • •Method of test: . .1.1(i iff• . . .24c,.For.Waref-Sumilv&Infection Wells: •In addition to sending the form to
" ' • .the address(es)-aboVc;.also-Submit-mid,:copy:of this form is •10:days:of
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13b,Dislitiectied type: •- )4T N • Ann:tint:.)Cer, D.z.,.- . . •completion of well.construction lo the county health department of the county
Where constructed... ,
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• ,Form CrW.-1. - ,