GW1--02468_Well Construction - GW1_20240423

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WELL:CONSTRUCTION RECORD'(GW=1) •For Ifttettlat Use Onlp: • • . '
I_:Well Contractorinformation: . . . . .
Chris King . . : . ... . .. . . . .. . . : . •. . .- ' .14.WATER ZONES ' .. . • . .f..I ' •- .. -
- •
- -- • FROM. TO • '_ - DESCRIPTION
• Well Contractor Name • :
2080-A . ' °7 R. 6i sr.. %. 1• .M • : .• • •- - . •
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NC Well Contractor Certificaiion Number : • 15:OUTER CASING(for'multi-cued wells)OR LINER(ifap livable) ,
Aqua Drill, Inc • - - . . H
FROM TO 'DIAMETER THICKNESS •M��ATERiAL,+
Cotppany)\'ome - .• • • . , 'R: fL in P/Z Ti 1A C ' .
}r• .16.INNER CASING OR TUBING(geothermal-Closed-loop)•'
• 2.Well C•onstruc•tio•n Permit•#: -•NV" P'.0 J t h• Dg I' FROM - TO - DIAMETER_` "_THICKNESS ' „:MATERIAL• '.
Gstall applicable iwil conslnrciionpe inftsf!a U/iL County.-State.Variance,etc.) • . R1 • R'- .. .'- In' •:
3.Well Use(check well use):. t. ;• f • . `ft to
WaterSuppy'Well:.. .•-• ''• .• . . • :. • THICKNESS . MATERIAL_.
• 17:SCREEN. • '
. $Agricultural: .. - Municipal/Publio. .. .o...ft.:. To .ft. DIAMETER.• FROM-1 w SLOT SIZE �
Geothermal(Hcating/Cooling Supply)' csidential Water Supply(single). .it .. .-ft.--. in, '. '
: ' . MI Industrial%Coranicrcial --, • Residential Water Supply(shared)
18:GROUT '
. • •• Irritation :. • • •FROM.•• TO MATERIAL. EMPLACEMENT METHOD&AMOUNT .. .
Non-Water Su"PY P l :Wells � ' ft. av R. �4yul3' :6tir, :
,�Monitoring: DRecovery :- tt (f.
.- injection Well: - -.-- _ -- .. _ .. . - .. . - . .— - _
*Aquifer Recharge: ' - DGroundwaterRemediation : :- ' - ' ` ' - — •'
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tt �. �. •
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19.SAND/GRAVEL. •PAQt(I1•appUphle) -
I'Aquifer Storage'and Recovery . Salinity Barrier. . -- • • ,. • FROM. . TO. • 'MATERIAL. - EMPLACESIEAT METHOD
$'Aquifer Test ... . • . [3Stormwater Drainage, :'•: • .• ' ...ft; • •ft:. 1... • - ••• • -
• :a Experimental Technology . • . :0Subsidence.Control ' . . • -:. '-. ft.. . • ft.. :- . .
i•Geothermal(Closed Loop) •. Tracer .' -.• -- . . 20.DRILLING LOG(attach additional sheets If accessary)'. . • • ,•
.• ' .. ' - . - . . , ' - Idr,baedntsR tail/rock Urock t pe.igiata dze etc.) '
Geothermal(Heating/Cooling Return) jOther(explain under 821 Remarks). FROM To DFscaMrnox(ea
D :a is y
4.Date Well(s)'Completed f-1`_`i '2q -Well ID#
• • - 3 .-I $0 ,ft•� Sf11v 4.• Z a t-.Ss.Wel Lo:cation: • • LJr .• /j 4•
e • • '
• ,d l .Facility/Owue Name Facility yiD#(ifapplicabie) . . l 1 •�. i -a I. ; •
i5sg5 jirifiliei .•I-J I) •R. . .—.. ..• : . " :
Physical Addnss,City,and Zip • • : R•• D• • A K'.b :•-L G. . .
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1,,,A . . 21.REMARKS •, 6tkA)q/i/7� _ - - - -' • -lr'r V T• -. •j ✓c'4,. '•-
County • • ParcclIdentifmcaiion:No (PIi4"' • • - • • •i tur.t'-:7'L'.- .
Sb.Latitude and longitude In degrees/minutes/seconds or:decimal degrees : ' • • • • . ' • -
(if well field.one lat/ong'is sufficient) '' ' • ' • •• . '
• a2:Certification ' . .. . ' . -
W .
6.Is(are)the wcll(s rmanent or jTem ora. .Signattirc�fied Well Coptic r ' • • Date
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Br'slgning this fono,I hereby ceri,[t that the mwJl(e)uus(were)constructed In'accordance
'7.Is this*a repair to an existing Well: *'Yes .or ONO . . . a 1thi;1SA NOW 02C.0100 or 15.9 NCAC 02C 0200 if el!Construction Standings end that'a . .
Uthis is a repair,fill out holm well consinn ilnn li firmminn an"t!erpiahn the nauare of the copy of tibia relvtrd hue been prodded talk irc!1 timer.- '
., repair tunder1121re,ndrly'seeiiniraroe'the buckifthi.cfeim. ' -
' 23.Site diagram or additional well detail:s
S.For"Geoprobe/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:
construction,onh.1 GW-1 is needed:Indicate TOTAL NUMBER of wells• • -construction details.You may also attach additional pages if necessary.- • .
drilled: . . . - , •.. � . .
}SUBMITTAL INSTRUCTIONS ;
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9.Total Rdldepth belotp land surface • (ft.) ',24a,For All Wells: Submit this form within 30 days of completion•of well
Far multiple:renslist all depths fdifercnr(esnniple 3(ra? 0'and3(u4100') -
�� conswction to thti-following: i -
10.Static water level below top of casing. ,i • • •(ft.) Division of Water Resources,Information Processing Unit,
limner er levet Is afore casing,air '+" 1 i 16 7 Kali Service Cinter,Raleigh,NC 27699-1617
11.Sorehole diameter: v (in.) 24b• .-For infection Wells: In addition.to sending the formate the address in,
'' above;also submit one•copy of this form within 30 days of completion of well
• 12.*Nell construction method: j J Z 12(� • . consiruetion to the following: - l( -
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(i.e.auger riflery.cable direct push.etc.) ' ' '
Division
FOR.Wall�,71Z SUPPLY' I LS ONLY.: ivis on of Water Resources,Underground Injection Control Program, •
f 'E 1636 Mail Service Center,Raleigh NC 27699-1636
13a.Yield(gpm) ` Method of test: S.t4.(A 14+• T.4c.For Water Supply&infection Wells: In addition to sending the form to
1 the'address(es) above, also submit one copy of this form within 30 days.of
13b.Disinfection type: Amount: Z. completion of well construction to the county health department of the county
where constructed. '