GW1--02259_Well Construction - GW1_20240409

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• WELL CoN8tRUCTIGN RECORD .GW 1 • • . . . . • . . . . . ..• -For Internal Use:Only: . .
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I.•Well Contractor Infortuation:
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• - • • .ChfiSr-Kielg • .• • •
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,A7 , , , . . , . . . .14.WATER ZONES. • ._- ' . • • •.
ell Contractor Naine-------- ---7--7----7--- FROM. - To.- . . 'DESCRIPTION
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. . ..2080-A:.
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NC Well Contraetor Certification Number• - - •
ft ft
.• • .. . • 15.OUTER•CASING(for nialti-cased.welli)OR LINER(If a !feeble).
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Aqua.- rill Inc. •
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• .FROM. • ,TO- - ' - • DIAMETER Y. I.THICKNESS. • MATERIAL . .
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Compaq Nome• : • .. . ' :!. ' - • : ft. CI i. 11.1.6) 1545'7.2:I : ....P V.(' : ..16.INNER CASING OR TUBING(Other:nal closed-IP)
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2.Well.COnstrnetion Peingt•#: • . . ,2..... • . • : . '-' . . •FROM.ft - .To, • :ft.. :DIAMETRER•' .• -THICKNESSIM MATERIAL •
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1,Ist allapplicahlewell cofignwilrnti.,ermitkae.111C,'Cotinot State.'Variance.era.) .. . ' ' !IL .
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X.Well Use(check well use). • . , . . . . ft: - :ft In ' •' •
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Water Supply Welk ' •-. . . .-. • • 17.SCREEN. -_' .. • • .• '
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4griculltir bMuniciPaininblic : . . : . ..FROM.ft.. TO. . :ft... .DIAMETEIK ;.SLOT SIZE .Tuicievess• MATERIAL
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•:,111,Geathirmal(Heating/Cooling Supply)• •EffieSideritial•Water Supply(iiiigle) -- . .• - .
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ti,Industrial/Commercial-- :DResidential Water Suliplirt.(sfiated)'. ' . .
•Illirri•ation 1 • • • GROUT
, • 1. , , • •most • . TO • • qVIATERIAL' . EMPLACEMENT-METHOD&AMOUNT
Non Water Simply Well ' - - •
• • : i.• I • • • I.I:DH ft'• .. 20 ft,. 564144e: ..chris(io 5 . .
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•iti MonitOring• . • ' ii.Recovery.. . • • . " - • ,ft, . • , . •ft.
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. .injection Well:. '
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. • -. . a Atiaifet-Recharge -. : D.QcoundWater.Remediaiithi. - .. ' • • • . -- • •• • .
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11Ailuifer Storage and Recovery tliSalinity BanIer . - - ' - • 'FROMSAND/GRAVEL PACK(If. TO • . ., 'MATERapplicable .EMPLACEMENT.METHOD . •
Si AqUifer Test .OStormwater Dmintigd . . • .. : - ft.. ', . .. It' . • . - • ! . '- ' : . . . .
. QSubsidence
Experimental Technology U
, : Control - - • - • - • ' :ft: • .• - •' .•ft-- " ! " • . •
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••jit Geothermal(Closed WOO- :DiTrnear • • - •20.DRILLING LOG(attach addltionalibeets If necessary): . . . - . . • : • •
.most • • TO- ' .. 'DESCRIPTION(color,hirdness,gall/rod lype;graIn sin,etc.) •... . ' .
eGecithprthal(licatitle/COblilil Return).:. I •iotherlex.lain utidtr.#21 Remarks)•
• , • . I . .-• 0 .•f!..• 3. ..ft... *Soli.- . . - . • . . . . ..
• 4.DateMell(s)Completed:,S,-19*to2:c/W ell m#: . • -- - . • ; : ft. 357 7-'"' Ari.-ici: gi c I . . - •
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5a.-Well Locallon:
:757.ft. cif)5-I'''. .5i,.c. '....4.-eigki.4 ca
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Facik/Owilqr•NamC ' ' . ..FaCiliIy.ID#(if iipplIcable) % : ' _ ft' : ' ft'. . . . I .r:77.;!;-.....;*. .7""17-‘:\
i . ,. ,.....•ki....c:I, V 4-.....6.---d .
..0V0- 'Jig-4 0-0 4 1 S it)r i w fic.IZ-C1' PrjelifiAlelvcr •. ... -'ft.'. .• - ft .-.,-.
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Physical Addrds,City,and Zit,
. . rt/i-C., • •. , - AIM 0-9 2024 . • .
.Cra_Shieff - . , . . . .. . 21.REMARKS. . • • • . •'County• • '
"Pared Identification No.(PIN) - -' : • • • Ink:rim:h.'h•Prnc.,5,7c:!Fig LitsA
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51.Latitude and longitude in dcgreesiniinutedseconds or decimal degrees: : ." . - : • ' • • . r • . ' . . . . r '
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(if well field:one latilong•is sufficient).
- :•- • 22.CettifiC- on ., , . • .
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.6.Is(aratbe•Well(s)dPermanent. ornTemporary . '*Sit,attire Of Cfied erti Wefi Contract r • : • ?•-•-Onto:19. 2y.
• • •ili.:awing this Aral herelv cerilh that the wnll(a).itv.s&ere)&instructed in accordance
7..Is this a repair to an eilsting-well: •DYes- or ON° • - with.15A NCAC 02C.0100 or 15.4 NCACO2C MOO,Well'Construction Standarile-and Atop. .
If Oh is.a repair.fill.nut known well cationtilion.infintatiOnand,cxplain the tiaturablilie cops.10411:1tvard haS been provided 10.the.well owner.
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repair under ti21 remarks sedittir or on the*hark of this farm..
• 2.3..glib diagram or additional-well details:.
You may use the back of this page to provide"additional well site details or well
S.For GeOprobe/DPT or Closed Loop Geothermal Wells having the same
construetio ,only 1 GW-1 is needed.Indicate TOTAL NUMBER Of well .construction details.-You may also attach additional pages if necessary.
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.drilled: .. - : . _
• •minimnu,INSTRUCTIONS-. . - - .
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9.Total well depth below land iorfice: 615-, ... •". (ft) 24a;FOr•All,Wells: -Submit this.fornit within.30.days:Of•completion Of:Well-
For mohinie-Arils list oil"(troths.if'different(eantpleL.30200 and 2(01001 - . .construction to the following:.• • :
10.Stade water level below-top closing; -1%0 . .' . (ft.)
Divisiou"of Water Resourcesilinfonnation Processing Unit,
If imicir kw 1 isf;have casing,usc-t." '
1617 Mali Service Center,Raleigh,NC 27699-1617•
-.11:Borehoie diameter: " ..6 _ • . (in.) -24b:For Infection Wells: In addition toi sending:the:forth.tO the addreis hi 24a
-‘... i above,also submit:one:copy of this-form-*ithin.30.days.of completion of well
12.Well construetion method: 1-71 I 1.-- .air ill . • : - construction to the following: I
(i.c.-auger,:rotary,cable,direct push;etc.). - .
• •• • • -• • • • • • • • • • • . . I Division of Water Resources,Underground InJectiOirCofitrol.Program,
•1636.1VIall.Service Center Raleigh,NC.276994636
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. 13a.Y4eld(gprit) . 0- - •Method of test IS;q irt+1 - . 24c.for.Water-SunnIV&Inleition Wells: •In addition to'sending the form to.
1...1-H 1.1 ,..,,H . • .the.address(es) above,".also'.submit•one copy:of this Ihmi within:30 days:of
13b:Bisitithetion type: j-I I . Amount 3 O. - 0' =4:. . - •completion of well.construction to the county health department of the county
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Fonn.GW.i