GW1--02821_Well Construction - GW1_20240506

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. . ' .!or intctntil Use Only;, .;.. . ' -_
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1.Well Contractor Information •
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Chris Kirig
Welt Cont King umc`
14.WATER ZONF� '
2080-A.. . : FRO\1. TO .-- -
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`ryt. DESCRIPTION
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NC Well Contractor Conificat;on Number
Aqua.Drill,,inc:
Compnny Nortic
UTER CASING for multi-MeldtveR4.OR LINER' i'a.ilicab
'FROMTO DIAMETER' ETNE 1!' •.
MATERIAL.. •: 1
2..We11.Construction Permit#: / '16.INNER C•'INC OR TUBING !eothermal dose List oil applicaFle lirll Con theilo0 pentr7ts art,.UIC,CouniA Slate.Parimtce.etc.) '. FROM- • TO - �tt. .'- 'DIAMETER THICKNESS
3.Well.Use,(check well use): . . . . Mini
- :is .
Water;Supply Well. Mt H: to
. : 1B Agricultural • • _ • . QMunicipal/Public• FROM • Dw. . .in sLorst� .
. .I,Gcotitetma!(HcatingiCooling.SupplY) ,r Rcsidcntial Water Sup l sin lc •.fL to .
NJindustriat/Comnicrcial ORosidential Water Supply(shared)' R.
. .:lstlrriQatioii I.. 1S® ® ®:. '..
Non-Watcr I.. • . Well: - ., .. • .. FROM' TO .. ' MATERIAL - EMPLACEss.FA sIETHOD&AMOUNT
II Monitoring DRccovcry , , •
I Monitoring:
:: .. .: .
e Aquife Recharge • :
OGroundwater Remedtatton'.- ft-
�tAquifer Storage and Rccove • ' ®' : '
tY �Selinity.Aarrjcr 19.SAND/GRAVEL PACK a'..limbic' -
. • �t Aquifer Stor . . : '
• FROat. TO" MATFRIAI._
... . ' EStormwater Drninage' - :.-ft. FMPiACF_�IENT METHOD: . - .. '
I Experimental:Technolo ' _
gY Subsidence Control ® `'
Geothetnl @ : R. ::IL', . . .
�` . . al(Closcii Loop) --�rT_rncer . .. . •�'.
Geothenual(Close g/Cooling Rotum 1_r • 20.DRILLING LOG(attach addiUonol sheets tiaeoesaary .•
Outer(ex.lain under i121:Rcmarlts): FROM- .. TO .DESCRIPTION eolor,haninrsi.soli/ruck .
st 0., ,to size eta
4.Date Wells)Completed: ,G
e Well iD# '
5a.Well Location: •: � al:I r-
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Facility Qlvn. • 'MI .•.g;
aciliq•IDl!(ifapplicnble) ft. '®
PhyslcalAd s:4uy.alai Zip.� J L® :tr •: i - : ,-, .
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•County - -- ty
.. cati0 No.(PIN) •
' iSli�rmrl
Parcel itictitifi a. T. . •
56."Ludaui3c longitude In degrees/minutes/seconds or decimal degreesc ' • -••' . - •
(if Well.:LittitUield.one and lon In�;••;•;, ; •:;t.-- yo
R is sufilcient) . • • - -. : •.. - •_ '•'. :j .,�. ..
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22:.Certi6catione
6.Is(are)tme vell(s) ' ettmtirient or
W
. Tcmporarj : • Signaturo ofCcrttficd c)1 Con sot
Date
7:Is tits-rep£-to an e:clSting.Iwell:' YCS Dr D• • Br signing dip firm.I herehi•cent!r dun hire.ut//(s)urrs(uere)ronstmeied in acr
Ifthis iv it l-pair;Jill ant kirnn,,ut•ll.ennslrnrtinn i fu,na,:on anti ccjt/ain►he'n:mut a nftlic R fliii,Alved iras f 9 once
mills/SA NGfC 02C..0100 or ISA.NCAC 02C.0300 nrll Onai,,retian Slartdan&ant dun u
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repair um/er r•21 remark'ssection nr on the hoick oflhlr fftrrt. I c4,'i u
• /men prorldcd tu.lhe tiz�ll uuncn'
8,For('rco rolitJDPT or Closed-Loop Geothermal.Wells Navin the same 23.Site diiagram or additional this well
tdetrovi. .
S For
n.o he I GW r t Closed-Loop
ed L p GeotharniAL NUMBERof to Same
You ma . .
gpage i it additional well-site details• . well
drilled: hidien consHuction details. You may also attach additional pages ifnecessttry.
9.Total well depth below land sgH'acec :. j� 5 -- SU�MITTAI,INSTRUCTIf�NS . . ' :
Formuhlple srcl/s li.+i all tlelitGs dipeirut(c�unr ilo-3tii_ (it') cons For•All Wells: Submit this fond'within 30 days of completion of well.
/ 90'anal_41001
10.Static water love)bclotw top of casing: � (
construction,to tho.followtng.,
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hrvirr/rt rl!s re l e riming;rase + • • (fkj Division of Water Resources !divination Processing Unit,
I.Boreholediameter. 1617 Mail Service Center;Raleigh;NC 276094617.
t� 24b.For llniectnn-Wells• in addition to sending the-fomi to the address in 24a.
l2.`-eli construction method:_ i " 1 1 above,-also submit one:copy of this form-within 30 days of completion of well
(i.e.auger,rotary,cublo,:direct push.etc.), construction to the following:
FOR�i1fa ftv • • • !: •"
f2 SUPPLS WELLS ONLY:: Division of Water Resources,Underground Injection Control Program,
13a I'lcId. m 1636 Mall Service Center;Raleigh,NC 27699-1636
.. . (!'R. ) ..S . iVlethod of test: '
• S ' • • 24c.For Water Su„ul,&Inlecttion 9Vclls; In addition to sending.the form to
13b.Dtsln:eciloil type: the.addresses) above, also submit.onef copy
.Amount:l C _a"� completion of well construction to the county health sdepamnenittof the: '
. where constructed. . . . I •• County
Form C,1V-1
North Carolina Department of,Environmental Quality•-I)hision of Water Resources
Revised 2-22-2016