GW1--02510_Well Construction - GW1_20240422

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WELL CO NiSTRRUCTION RECORD,((bW=1) For Internal Use-Only: -
1.Well Contractor Information:
•• Chris King
• 14:WATER ZONES
Well Contractor Neale.. . • • FROM. TO DESCRIPTION'
•2080-A P . 26 7it.• .�-¢ -i'p • ;i.. . : :' .
NC Well Centimeter Certification Number
1S:•OUTER CASING(for multkased wells)OR LINER(trap 0eabie) ' .• ---- -•
Aqua Drill; inc. • -
FROM 'TO DIAMETER- 'THICKNESS- MATERIAL
Company Name • 6/t in its .
t ''f ' j �p • .16:IN ER ASI RT BING(geothermal'dosed-loop)''
2.WellConstruction•Permit!/p43" 95�(.J t ry 2.I - FROMN :..•TONG TUBING
.• • THICKNESS . .-MATERIAL
(( O
Llit all applicable null construction pennrtc(F e:UiC.Counts Stater'Yariance..etc.) ft. • ft:' : • ia•' • .
3.Well'Use(check well"use): -- • fy`.. ' ft.: ' •le. . : -
• Water Supply.Well::: . •-- '. .: 17.SCREEN" _ .
Agricultural - - .. 'ErER ; SLOT SIZE - THICKNESS MATERIAL
FROM. TO . -' DtAA
Municrpal/Public
Geothermal(Hcating/Coaling Supply). esidential WaterSupply(single)
Industrials ommcrcial . :0 Residential Water Supply(shared)
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Irrigation • ' .. .
.R H 'lo. -
•its.GROUT
•. . - ., ' - . ' , . FROM • TO. -' . .MATERIAL.'. EMPLACEMENT METHOD'&AMOUNT.
Non-Water Supply Well: . : .. • ft: O.. R.'
Monitoring. �Rccovcry. na.S
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fwl;le c.tr`ps
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. Injection Well: . . . -- .
• . . ufer Recharge d ft. .: fZ
A9 i� R � •. Graundwtiter Retriediation -
Aquifer Storage end Recovery, lSalinityBarrier. . . •
FROM••. TO Of
. EMPACE.MIENT.METHOD
PACK
•
Aquifer Test •
'- � �Stotinwater-Drainage tt.''. . ft.'
Experimental Technology QSubsidence Control ft.• • • •
Geothermal(Closed Loop) Tracer' 0:DRILLING LOG(attach additional sheets If necessary)'
. z _
Geothemral(Heating/Cooling Remritj r1Otiiei(explaiqunder;ta liRetfiarks) EOM TO. ' .. .- DPSCRIPTION(rotor,turddcti solUrock'type;'gain sin.. etc.);
cJ �.. ti..ra t�.:.,: : . • Red' 'C1lay
4.Dote Wells)Completed:.. 8 - (Weil ID# • . ••ft.. R.• -
Ss:Well,Location: APR 21. 'lU14 7-f.' 96:-:.:ft. .iiIf.!c ' ef—iiki ii14P - :
;:t ^, ;F••;r."-.j U �0' IL:
t. J'01714' i1 t)d �.Ct 13iad ed lip 12dCIC
FacltyOwi Nnmc • • ` 1t ehtyI 7(i "p liealil.)• !B y-�. ��5 • i31tic- CrL�� � . .. .
j751 �'lZea. /Y�J 1 ^� ft. ft. .
Physical Address,City,and Zip •
21:
County '. - Paicel Identification NO.(PIN) "1 O 1 u Sr )3rz i fr c.1 f J O t'yy
Sb,Latitude and longitude in tlegreeslminutes/seconds or decimal degrees:
(if well field.one latilong is sufficient) 22.Certification:
N
W
6;Is(are)•tlie-Wells) rmanent or r-�y,Temo• Signature of certified Well Contractor -•.' "• D
L)' P �' Date
Br sibming ilile;jhn i•ccit4 ir,I hereh :Ina the toYal(s)iws(irere)cunc:rved In.accaiilance
7.Is this a repair to an ranting well Yes .or IVo, ... Ullh ISA.NCAC 02C.0100 or.154 NCAC•02C 0200 Well ConinMtton Standards and:hula Ifu i/c is a repair,fll out knnuir well mask:n iron Infnnnwlar and csplain ilie nature of lire cnppr of thin rerun!hac been prodded to the i a!!owner.
repair wider 021 mnmrki vet or on the hack Of this:form. ' '
' 23.Site diagram or additional well details:
8..For Geoprobe/APT 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;onlyy 1 GW-1 is needed. Indicate TOTAL NUMBER.of wells' construction details: You may else attach additional pages if necessary.
drilled: . ;.
nn SUBMITTAL INSTRUCTIONS'
9.Total�ietl•dcpth 6clowland surface: a4 (ft.) • " • i.
For multiple t r is list'all depths if dy)ercut(e ample,-3(0200'and 2(0100') con For Alt.thell Submit this form within 30 days of completion of well
,y construction to the following:.
llowing:
• 10.•Static water-level below top of casing: 2 v (ft.) 1
Ifunter lere1 is shave cas(rg.use O.+" Dh l§Ian of Water.Resources,Information Processing Unit,
1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: - aQ. (in.) 246.For Injection'Wells: In addition to sending the form to the'address in 24a
12 12:Well construction method: j. Z • IZ 1 above,also submit one'dopy of this;form within 30 days of completion of well
Well,rotary,Cable,uctio direct push.cfc;)
�. Construction to the following:
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FOlt Pdn1 1:13 S[JP)t LY dd'ELLS ONLY ' • . Division of Water Resources,Underground Injection Control Program;
'a 1 1636'Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gprr!) Method of test: . ,i q rl er 24c.For Water Supply-&Injection.Wells: In addition to,sending the form to
i �^ the,address(es) above,:also submit one'copy of this form within 30 days of
13b.Disinfection type: /// Amount: f 6 -0•, completion of well construction to the county health department of the county
where constructed.
Form G\V-I .. .. —