GW1--02494_Well Construction - GW1_20240422

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WELL CCNST RUCTION RECORD GW 1 • ` n '
ForIntelnnl Use Only:
..1.Well C ontractor Information:
Chris King . : .
• 14:WATER ZONES .+
' ' ' Well ContractorN�ame :
FROM TO DESCRIPTION '
. . • p2c1O ft -9/ Cl ((P(.p • •
NC Well Contractor Certification Number '
Aqua'• Drill, Inc.. .. • - . ,1S.-OUTER CASING(for.malH-cased wells)OR LINER(if ap Ilcable)
FROM TO_ DIAMETER THICKNESS. • MATERIAL .
Company home �
C0: II-
-10 a It. , /Y •tea. 56t i' �P' r G ` • '
2 Well Constrpchon •Permit#: ;Z a-3 6 . . 16.INNER CASING OR TUBING(geothermal closed-loop)List all appIleahle urll can stnrelion pennits'(i.e.U/C:Corn h:State,„Variance.'etc.) tt .� '
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FRO TO
.DIAMETER • THICKNESS' MATERIAL
3.Well Use(check well use):.. •Water Supply Well: :. -
. . _ • �• 17.SCREEN- : '
R• ,•ID..
a Agricultural .• • FROM _ TO •�MunicipaUPublic DLin9E1'ER .sLOTsizE THICKtCt .• MATERIAL.
■tGcothermal.(Heating/Coolin Su I • is '
• g_ PP Y) � .��t¢sidential Water Supply(singlg) �' •ailndustrial/Comnicrcial • ' ' K in: •
Residential Water Supply(shared)
(i!LTiQalion .. . - • '
Nou-Waon Su 1.Well:. • .
' RouT
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. pp y .- • • MATE AL �• EMRWCEMENTMEfFiOD&'AMOUNT -
1VIonito er • w .
FROMTO
Injection Weli:.. - `` • .
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>:AgaiferRecliatge R. -• --
Groundwater Remedietitin •.' kAquifer•Storage and Recovery l..ISalinity Barney 19.SAND/GRAVEL PACK(ifupplte'6le) •. . • ..
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FROS . . TO. MATERIAL�tAquifer lest . 'EMPLACEUIENTMETHOD. . '
Stormwater-Drainage ft:. . g,
f•Experimental Technology - - : OSubsidence Control • •
•• Geothermal(Closed Loopj• • • •" ' Trne•er •• • • • • • -•
• R ft
Geothermal(Heating/Cooling Return) Other(explain under.il21•Remarks) 20.DRILLING LOG(attach additional Sheets If necessary)• ' •
FROM- •
TO ' . .DFSCRIPTION(rotor,hardness,saterock type.grain stag eta)
R • ft:
4..Date Well(s)Completed•�)77? .4 G_I Well iD# • • .R - ft Ikd } •• ri. .; • • y
5a.WeA Location: • '. S sbr� ‹aluti go.c.C .. .
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Facility Ow»s-Name
• Facility ID#(ifepphcable) ft. •'ft°. i r .
3 N():T\fri f 1.-- IZcL (NIA 11 1 e f: :. • :'.: : •ft. :: . ' ft. n R 2 2024 .�PPh'(ysical Address,City,and zip : R: k. P
l -J• C� c
.Cann
Parcel Identification No.(PIN)
Sib Latitude:and longitude in degrees/minutea/seconds or decimal degrees;
' : (if well field:one Iat/long is sufficient)`
22..Certilication:.
W r�
. Gi 6.Is(aro)the well(sPermanent or. OTemporar)• • • Signature ofCcrtrfted We 1 Contra at. ... • • Date
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• $t signing this font;I!retch.centhtihat the ucll(.r)ivae(were)lvnartn(e•{ed in accorda(icte
7-Is.this a repair to an existing•well: Dyes or No ' . nigh 15A NGIC 02C.-0100 or 154 NCAC 026.0200 Hell Consk:mine Standards and that a
If tlis is a repielr,fill ow hnunn n e/i c onrtnlclion hilhr iratlnn end eirplain the natere(Oho Earn'of i/iis record has been prririded in the ud!inviter..
.repair tinder ter?I remarks.rci tron.ar uq the Burt of lIaLvfrirnc
' . 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop•Geothermal Wells havingthe same • You'may use the back•of this page to provide.additional"well site details._or well
construction.only"OW-I is needed: Indicate TOTAL NUMBER of wells • construction details.You may also attach additional pages if necessary
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drilled:
SUBMITTAL-INSTRUCTIONS • '
9.Total well •
•depth•below •land surface: • • .�+r•'� • (ft.•) '24a.• -For All Wells; Submit this form wit•hin 30'da
For ntehiplc.urllrslistupdepthstfdtfferefit(rmmple-30,200'and?(ry100ry 'days-of Completion of well
• 10..Static water level below top of casing;. e.0 .(ft.). c nstTtctiDivision of 1Wat Resources,
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Iju,otrr lcrcl is eboi a casing use"+ pnfotrniatlon Processing Unit,
1617 _Mail Service Center;Rsieigh;INC 27699=1617
11.'Boretioledtametr; ,6 (in.);
. 246:For fnjection'Wells In addition to sending the form to the address in 24a
12.Well construction method: f 9)17 d�l.[Z j 1 _. . above,also submit one'copy of this form within 30 days of completion of well
. (i.e.auger,rotary,cable,direct push,etc-) construction to the following: • ;
FOR WATERSUPPLY WELLS ONLY: Division of.Water Resoui cos,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,.NC 27699-1636•
13a..Yiold(gpsn) : Method of test: ( 24c.For Water Supply 8i lfnlectlon Wells In addition to sending the form to
/ the addresses) above, also submit one]copy of this form.within 30 days.of
13h'.Disinfection type:. H774 Amount: I(O. .(Y 2_ . . completion of well construction to the county health department of the county
where constructed:
- Fonn G1V-1