GW1--02398_Well Construction - GW1_20240423

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WE "(CONSTRUCTION R 1) I'ForT ntemal Use
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ECORD(GW .. •
LL •
• Only: •"
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-1:Well_Contractor_Information:
.Chris King
14.WATER ZONES . I
Well Contractor Name• •• ' ' FROM . ' • TO DESCRIPTION I.- f '
• ..2080-A -)5 • )56- "fc: '.4 .6.ipi1'1'ii i. . • .
NC• 'Well Contractor Certifcation Number'' •
Aqua,Drill;.Inc:-
15,.OUTER CASING(for multi-cased Wens)OR LINER(if a licable)• '.:-••'
._-.. - 'FROM -' I TO-' DNMETER THICKNESS� '.:- "�TERIAL '-
'.'Company Name " • • • - . 0-. it• o•�'•ft:'1 G�H is,l Sr�lZ.71• : hd;-U''C _
/��� 67 • 16.INNER CASING OR TUBING(geothermal closed-loop).
2 Well Conslrye1L8It min. 1411. :Va ) -V,2 $ � ." FROM. TO DIAMETER THICKNESS MATERIAL "
Ustall applicable awl!constrncrionperntfrs(l e.UIG,Counh.State.yariwice etc). ' ft.. R. 1m "
. '.• " 3.Well.Use(check well use . •• f. , R: • In • . .
Water Supply Well: . - :.. " ." • . • . 17:SCREEN. .
FROM •- TO DIAMETER SLOT SIZE - THICKNESS'-. •MATERIAL -
• Agricultural '' . ' ©Municipal/Public
,.•• ' Geothermal(Hcating/Cooling Supply) csidential Water Supply(single) :
ft. ft 1p..
fi.
.. Industnal/Comttiorcial DRcsidcntial Water Supply(shared)
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.Non-Water Supply ' .. : ' • o ft 0 ft.; )382,06V pt
. FROM
TO ATERi •EMPLACEMENTMETHOD k Aa OUIVT
NS.
. Monitoring . . .nRccovcry• ,. . _ • .. :ft.- .re...-- . : 1
injection Well: ; •
Aquifer Recharge . . EjGronndwatei'Remediaton
Aquifer Story i'and Recovery • . 19 SAND GRAVE (If applicable) ..
/ L PACK
g Salinity Barrier " T AL
Aquifer Test . • • •DStormwater Drainage- • " �I n•:• D •
• ft. MATERIAL :
FRO ATRRi EMPLACEMENT METHOD
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Experimental Technology. • : OSubsidence:Control - iL' • it •
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Geothermal(Closed Loop)• • • • DTracer: : • .20;DRILLING LOG_ (attach additional sheets If necessary) .
Geothermal(Hcating/Cooling Return)• ' ather(explain under#21;Remarks)' 'FROM TO DESCRIPTION(color,hardnesv raNroekgpq Grata size,eta) .
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SO
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4.Date Well(s)C "Pletedi t- -14 `at'SWell iDit ." a f( .ft.: . : : :...._.• -
f.� .S�Y�: 1�aty
a.Well Location: � • ft.. tiff
IS" .. �3"lu�. �Rwn�i.-1 e. . .
li%1tgC�►t) t-o-:• ft. e. e
Paciliiy/Owner Nark . Facility ID#.(ifapplicablej • •• 1I•. . .. • ..
' •'-4;�i " .r r' • ar. a ,
o : j C •$7- 1Ji/.)5&41 i iao)Lt: �v°C. .' "n.. a. ' .,�I'R -•i."
`� �.f174
PPhhyssical Address City;and Zip ft" ft"
v itr� j'''. 21 REMARKS c.•". `' `r a it
County: ' • ' ' . Parcel No..(PIM
Sb:Latitude:and longitude in degree's/inin)itesfseconds'or decimal degreei: :
(if well Bold.onelet/longis sufficient) • 22.Certlfca on: '
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• . c
q...7/6 -.2. l•:
.. 6.Is(are)the well(seermanent _or OTeinPo..
rary ;Signatiob'of Certified Well Contract ' Date
Bicignbig tills farm.!hercl,i•earl j.that the xn//(s)was(Hare)contra tell in at:corrlunce•
. : 7 Is this a repair to'an existing Well: DYes 'or �.r.j:No with ISA NC:AC 02C'.0100.or 15.4.NCAC 02C.0200 frail Constriction Standards and that a -
lilhc&is a.m.air,fell art knaun wellcma in,,Noe informatin i antiexplalil Ilse&hair grille 'aa)ti•of flits retard%mar hien prn ided hi the well au ncr.
repair ender k21 remarks Section or on thi had i fllils faiwt:' ' .-
23:Site diagram or additional well details: •"
. 8.For Gcoprobe/DPT or Closed=Loop Geothermal Wells having the.Sarre • You may Use the_back of this page-to provide additional well site details Or.well'
;construction;only,I OW=I is needed. Indicate TOTAL NUMBERof wells construction details.,You may also attach additional pages it necessary.'
'SUBMITTAL INSTRUCTIONS
9.Total trell depth below land surface: ....2 . . . . •
Fornitrltiplc'i'rclls list all depths fdldferen(erample-30200'mid 1(ri1100_') (ft)•
consFor All the foil Submit this form within 30 days.of completion Of.well.
construction to the following.
10.Static water level below top of casing: •
!Jaamr/rrc(!snh le el be;useop
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O Division of water,Resources,Infoiinatlon Processing Unit,
1617 Mail Service Center,Raleigh,NC27699-161.7- ' •
11:Borehole diameter: (in:)
246.For Infection Wells: ,In addition to sending_the fort to the address in 24a
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12.Weil construction niethodi. - I it6 -1 )1.
'above,also submit-one copy of this form within 30-days-of completion'of well
lie:auger rotary,cable,dii�ectpush,etc.)" construction to the following:•
F01�Wla'S&R&UPPLS'.WELLS"O\ZY:' Division o_f.Water RI sources,Underground Injection Control Program, •
1636 Mail_Service Center,Ralefgb,RC27699-1636 . • . .
13ti.Yiclti C ,I i
(rpm) " • Method of test:. J£6 h�: 24c For•Water Sutpl�'&Infection Wells: In addition to sending the foam to
136.Disinfection H the address(es) a 30 above)also submit one copy'of this form within days of
type: T Amount: I o completion of weld cdnstruction to the county health department of the county
where constructed,
FomrOW-I
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North Carolina DcoartnientafF„i,hs,nn,..,;,,,in...,r:... n:..:-:._.n.... ..