GW1--02820_Well Construction - GW1_20240506

: . • •ddltL➢;1L Q:QDt�► 'Il71dUCTIJ®ITT YYIECOISYD. : :
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For Internal.Use Only:•• - _ -
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1:Well Contras or'Information;
: : • ._ : Chris King . •
WCII.ContrnetorName ' .. .
.. 14,WATER ZONES.. •• -.. . I
• FROM-, TO
•
. DESCRIPTION
2 =A n, I .
08q .. . .
K weli Conimcior Certification Number .
Aqua Drill; Inc.'. .
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IS.OUTER CASING for multitased Wells OR LINER if it: sable '
Company Drill
TO .� • DIA!HErER 'THICKNESS MATERIAL-
2.Well ConstructloD Permit#: /. ��•. •• -16,INNER CASING OR TUBING eothermmi closeddoo, • .. . •
Lit,all nlrp/fc ahfe nrll.cattWrircllori pernrfls(I.e. 1C County.Suite,Ponance.,etc) ' FROM.•
:ft.: •TO • .. 'DIAMETER• •. •THICKNESS• '
•• -3:Well Use(check-well.use):
. • R • fo. MATERIAL • .
Water Supply Wcll: •
'• 11 tt. )o
Agncultuml. • Si
DMunicipal/Pubhc -
• 'FROM
REE1
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,®Geothermal(Heating/Cooling Supply) (&saidrnual Water Supply(single)::
TO
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'DIAMETER SLtYI'SI7.E :THICKNESS MATERIAL• .
ft: •• In. '
Industrial/Comiticrcial- f—� ft: :tI: Its .
�!1n 'trisli DResidential:WatcrSupply(shared)
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Non-Wlon Supply We..
FROM 0 MATERLAL:• •• • • .•CE_MENrMETHOD.igpfOUNf
•Monitoring , DRecovcry. .' : . INgir r i ,�•
Injection Wcll: :.
: . Is'Aquifcr:Rcchti .e
InGrotindwaterRemediation • •:ft'
�:AqurfettiStorago and Recovery Salinity Barnet • 19.SAND/GRAVEL PACK If a .Iteable •-
FROM•
. EMPi ACF 11F]17 METHOD
' ' : .1siAqulferfiest. Sfarrntitet I) .:. . ® 11111111111111 MATERIAL. ,• .- .. . � er rnmage. tt: . .
••ExpenmentalTechnology.-. DSubsidenc0Contr_ol -
Geothenra!(Closed hoop) Trucer. ' ' : . • R: ' : • •
Geothermal(Heating/Cooling Return).• I Other(ex under#21,Remadcs) 20:DRILLLYG LOG attach nESCRI T sheet; f necessary
. .. _ 'TO. .DESCRIPTION color,Nitta . soly k .,.'I. to etc. '.
•4.Date We11(s),Completed Well ID# • • • • ' .=1: • •
. . Sa.Well Location c��8-ettidlw r 'J d
Faciliryt(hvnr:Nann:' ' .Facility.lDfl(ifappiicabic) R.
• 11 ' tt•
Physical Addn s.City hn�Zip .. • t/ A. N d r, . ,L a,,` -
. Ste.t 2t.'REMARI(fi • '. ?r d
County
Parcel idenufieatioa No'(PIN). .
Sb Latitude and longitude In degrees(minutes/seconds or decitnai d rw� . .3 �a
egteesr
:(if Well rem,cab lai/long is sufficient) . �'t e
22:Certipicat(one
:6:Is(are)the�iep(s)r^/ipe nent or
• Temporary Sigctaturc ofCcniHctl We Comm
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7.is this a recnals to an existing well: ,Wes or Br.signing ads firms,1 hardy ccr4/it,that the wcf/(c)nnr(Ivor)conslntrled In accordance
fir/itsLs.drrpair,fillnalhnaun.tiel/ttocrtrm•linnitjrrntuRanrrurex laini/renanai"ft/rc clrRvnf/h�rurt•art!lrasJxenprat•Idcdkrt a it//miner.
C 0- or/SA-NC- . 0_C;0_00 Well Conslnrctfgn Standards.widths a.
"rc%rulr under t;?1 renturks section or ou the hurl•rjddsjnrar.
' • 23:Site diagram'or additionalwell details: . •
8.For Geoprob'e/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 -
coastntct on.only I OW,I is needed...Indicate TOTAL'NUMBF.R ofwells drilled: • constntction.details. You may also attach additioaaipages-if necessary
(_,( SUBMITTAL INSTRUCT ONS.
'9 Total:Weil depth below land surface 1
Forntnpijrlr rr/h/1,ra/Idept/itj d trriillrramp/c 3liq?g nil.?tir?(!p,). (ft') 24a For.All �Wella: .Submtt this forth Within 30 days of completion of•well
10..Stair thater level below top.of easing:� � 'consuuction:to the following: I
Winder lrrcl is Olive rasing,tire +• ' 0 (It:)
Division of Water Ice Centel',
e ccsr Raleigh, n Processing.Uuit;
11.Borehole diameter:. 1617 Mail Service Center;'Raleigh,NC 276994617 '(In.) 24b.For�Inieetion•Welis: In addition to sending the fortis to the address in 24a
•
above,also submit one copy of this form within 30 days of completion'of well
(i.c.auger, fy,cable dit>et push etc.) • construction to the:following:
Nla
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FOit tyA7Li2$UPALb'WELLS ONLY: Division of Water Resources;Underground
rground Injection Control Program,
1636 Maii:Seridee Center,Raleigh;NC27699-1630 :
13a.YIcId(Om) Method of ecst:
24c:For Water SunDl &In ection'We11s; In addition to sending the forth-to
136 DI§inscctio l type • •: the address(cs) above; also submit one co 'of.this-form within.30•days
. Amount:'1 r' t�2 completion of well construction to the corinty health department of the county• .. -where constreeted.
PoirS G1v-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016