GW1--02715_Well Construction - GW1_20240507

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WELL.CONSTRUCTION RECORD.(GW 1) For Internal Use Only: -
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• 1.Well Contractor Information:
.•Chris King. _ . :. .
14.WATER ZONES
Well Contractor Name FROM '. TO.•• :. 'DESCRIPTION • '' _
208bA" is '0 .!
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.NC Well Contractor Certification Number
:IS:OUTER CASING(for multi-cased wells);OR LINER(If ap"liable):• ' '
: Aqua,"Drill,:Inc.. . - . . . :- •• . . FROM- • TO .• • ' •DIAMETER: . THICKNESS ' . .MATERIAL'
Company Name • .. 0.. 6 '( . •Cr? O'Ai .SD lZ 2•I al(AC:- .
. 16:INNER CASING OR TUBING(geothermal dosed-loop) - •
• 2.Well Construction Permit#:(4)'2 D.X3 / :FROM• TO_.-. .DIAMETER' . THICKNESS ' MATERIAL-• . • '
List.all oppldcahie will construction permits.(i.e.UIC Conan State.Yarlanee etc.) R IL• h'
. 3.Well Ilse(check well use): Yt:'
.Water:Supply.Well:- -_ -
'FROM.. TO-. '' ' . DIAMETER ''SLOT SIZE :. -THICKNESS . •MATERIAL - •
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. • Agricultural . •'X Mtinici aliPublie• - _ •
P R: tt: !n •
Gcothcrriinl(Heating/Cooling Supply). On l Rosidential WaterSupply(single)
lndustriril/Commcr'cial • QResidcntial Water Supply(shared) .
ft.
R:
irrigation . •
Pp Y .. - UT AL "EMPLACEMENT METHOD&'MfOUNT
Non=Water Su 1 'Well:' ' _ . . ft ' R. . . •'.
$ •• ' rROM TO. •MATERI
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• D c 631!i1.4 J t' Chips
Monitoring .. . "_ Rccovary : -•ft. ,:.ft.• • . . • .
- Injection Well: . • • -•' . :
" Aquifer Recharge • . :Groundwater Remediation - =- •
AquiferStorage and Recovery Salini 19.SAND/GRAVEL PACK applicable) .•- • ': :
ty Barrier FROM•• ' •TO, MATRRTAL EMPLACF.9IENT METHOD.-.
. Aquifer Test • , . . , .: QStormwater.Drainage .. : R• ft:
ExPTechnology Sub"sidcnce Control R: : it:
erimental '� •
Geotherral(Closed Loop)' •'. Tracer • - • 20.DRILLING LOG(attach additional sheets If necessary)_ : •
Geothermal-(Heating/Cooling Return)• flOther:(explain under#21.Remarks) FROM" ' •To ' DFCRII'TION(color,bardacss;soNrock titita arala aiu;etc.)::
. 4:Date Well(a)Completed: _.- . oZ: W•el•l 1D#• 6-:••:ft:• .I •.ft'• :r'•4 Ja '•IZQe t' • :
5e..:Well Location: R 32. ••�. I3' 0 • 9 .I1ir17i
:t R/./143-rin Fd�ii •ri: ft - • .
Facilit Own Name ft R y FaciliryaDN(if ' - .• . . -
' 7- 'f if -f; • ¢ .r b»,- .••ui..-.I . a e
. • 1o3IIInl2135 t)y: e d i ' &izdve . "' . tiOPhysicalAddru.City,andZp ..' . . _ - -..,• :.• • : :MAY . : :..iZ4.. ;
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ZI..REMARKS
County. Parcel Identific (P1M.. - : ItYt`vi'r..:.4 r ?•-•_ J;;,; ,g 1..„.,, _ ..
scion No ._ .
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: • -: _.
(dwellfidfd.one Iatllong is sufficient) ' '
22.CertitIc'eon;
W
6.Is(are)the well(s Permanent •or•OTemporary Signature o Certi d We Contra Date r ••
By:signing this fnr,t,.1 herehp rent•that the ur/)(s).tine_(were)con:tnrrletl in accordance
7.Is this a repair to an existing well: .DYes. or•kNo with.1SA I'.C4C 02C.0100 or 15.4 NCAC 02C.0200 Hell Construction SlantlareLe and ilmt a'
If this iv a repitir,fill ant known wen consNrvrllon information and atlrlaiir the nature of the' r'r9?t'r flhlr let a,d lias been prosk d is the will ounrr•
repelr under 0121 remarkv.section oronthihackrfIl,iefruac '
' 23.Site diagram or additional well details: ::,i
• 8.For Gcoprobc/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
constnictio:r;only.1 GW-1 is needed. Indicate TOTAL NUMBER:of wells .construction details. You may also:attach additional pages if necessary:
drilled: . •. .
SUBMITTAL INSTRUCTIONS
• 9.Total well depth below land surface: 3 ,7 . ' (ft.) 24a.For All Welle: Submit•this'form within 30.days of completion of well
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For multiple:ells livi all depths IIf diferent(ecample 3(w200'and 204/00) ' " ' '
'construction to The following:
b•
10:Static water level below to "of eosin !' - '
P C 0 (fL) Division of Water Resources,Information Processing tall,
If uvw titr cl is rrbot a C u sing,tag^+ 1617 Mail Service Center,Raleigh,ANC 27699=1617
I I.Borehole diatheter: .. • .6 (In.) 24b.For lnlection Wells:_In addition to sending the form to the address in 24a
' ." - above:also submit.one copy-of this form within.30 days of completion of well
12.Weil construction Method:.•i 1 i IZ : 12 I 1 I . . construction'to the following
(i.e.auger,ro)ary,cable.direct push,etc.j ' •
• Division of Water Resources,Underground Injection..Control Program,
FORWATER SUPPLY WELLS:ONLY: • ' 1636 Mail Service Center,;Ralelgh,'NC 27699-1636
13a.4'leld( pm) -3 . - Method of test:: (( A a.+ - 24c.For Water Supply&'Injection Wells: In:addition to'sending.the forn'i to •
�`f !) the addressees) above;also submit'one copy of this form within"30 days of
13b.Disinfection type: / f7 Amount:/4 completion of well construction to the county health department of the county
where constructed.
Form cm-1 North Carolina Department of Environmental Quality-Division of Water Recnnrcrs o...:._.r-•ew.,fl.k