GW1--02909_Well Construction - GW1_20240510

•
•
N6tIILIl�iL uI�l 'll'Il(UCTII®I�1 y81E�®IS➢➢ 1 .
• For Internal Use Only:
I:Well Contr:icfor Information; •
Cliffs•King. : .
Wd1.Contm60r Nume
14.WATER ZONES
FROM•, TO DESCRIPTION'
2080-A
_ dam '.: .
NC'Well Ciunmctor Certification Number n•. ft:
Aqua Drill; Inc. • 15.OUTER.CASING for mult4cased wells OR LINER f a. lienble ' .• • .'
. . ..
FROM TO. DIAMETER ' THICKNESS ••' 'MATERIAL' ..
Company Nntnc /� fl:
j • V. Q': D. �� tu. S.Ot f af`. .
:.-. -• : •.
••2.Well Construction Permit#: /.-� .16.INNER CASING OR TUBING •eothermal dosed loo . - -. • -
LLw fill app/irahle well.canRrnrc!loripenults(r.e. 1_C.Cortnli Stele,Vatimrce.etc.) FROD9 'k. TO .. DIAMETER' - "THICKNESS-'
MATERIAL
3:
ft
•
f. in.Well Use(check well use):
• .Water Supply•Wcll:.
17.SCREEN'.. _ • .. . . � .
1l�jAgricUupral ®MunlcipaUPabl(c •
FROM TO :' DIAMETER SLOT SIZE TDICKAF$g..
MATERIAL ft: )o ATERIAL'Gcothctriial(Heating/Cooling Supply) : Residential Water Supply(single) . :
ji InilustrtaliComitierciei .• Residential Water Supply(shared) • • n' ' .R: • to. • • • • .
• l♦1Intieatton. .
18.GROUT ...
;NOII=W:ttcr Supply Vp/eB;` . . •Films:' •TO- '` 'MATERIAL' EMPLEMEN
A•CT METHOD @ AMOUNT.
It Monitorerg ;
I Monitu Vk'ell; • DReeovcry
I Agnion Rcchan e •
. • .: tt
: DGroundwater Remediation :.ft. R ' . -•:.
e♦AqutfenStornga and Recovery Salinity[farrier 19.SAND/GRAVEL PACK If cable
*Amara Test • FROM . TO MATPRIAL. .- EIVIPLACFg1EAT METHOb
1q.l;xpenme»tal Technolo �Starmtvater Dminag . •e ft ft.
gy Subsidence Control • fL
Geothermal(Closed Loop) •Tracer• . • " � ft: .
Geothermal(Heating/Cooling Return) ' 1: O t7in' ft'
fier"(ex safe under d2l•Rctitarks)
DRILLING LOG attach additional sheets if uecessai'
••
'To_ DRSCRIPTION(w[ar.baidn�•. saNrock ._ •Iastrr.ctq
4.Date Wel(s)Completed •'
�J`�
•
•
• 5a:Well Location •
•
M L t `' d::• dG• :"' ' - : -
B .
Facility.Qrvtrr*faun:•.. Q ft.•
racility ID#(if applicable) .
'• Pbysirnl Addi.,tis,Cit � -.v .0 �'' •, + ,_, a .. .;j ' :- '
•
County
Parcel Idcronfication No.(PIN) -• • !r;v .:* r� r•.- :'6:'t7 tJ;
• Sb:Latitude and longitude in degrees/minutes/Secon&or dec•iina! •(ifwell ficW:ups latticing is sufficient) .• degrees: J
22:Certltication: ' •
6.Is(arc)the Wcll(s)'~/iPermanent Or. Tcm'!o .
D. rary Signature Of:milled we Contmc •• '
•
Z Is tlils tt repL+t.,to an existing well: �Yes or.Ip��.k`,,�� Bi'slbrring I¢/.c fillet•I herehi;coil&rhai the wel/(s)wee(heir)tnnsafrcled•In accotJance•
• {ldrls Le atc xrir; dl eelAnoun_n e/1 cgr.trectnn lnftrrnimla,,lair/ev laln die nalui•t�tithe ,opr of di(ref k�i ha ehee,, i cis Jo�C0 C lxll mrwer
f p C:0_0O ll'e/I Conslr�rclitin Slan�forrle ant/r/rot a.
'irpu/r under r?1 ranrurke section or on Hiebut k rjdiiejrrur. •
cvi P
•
' 0.For Geo robe/DPT or ci Closed-Lo Geotberroal Wells having"he same 'you
tuR he.back of)this page,to pro ide additional well site details or well
p p Yu may.construction,only•I OW+I is needed. Indicate TOTAL NtiMBER of wells drilled: constlilction.details. You may also attach additional pages if necessary.
9.Total:rtell death bclotvhind surface (_,f( S°BMITTAL INSTRUCTIONS. •
For multiple:iclle lips all dt 7hs•Jr u•efil lamer le-3ira_7 ua hq- (ft.) •P if p p , • 24a.truct All Wells•;' .Submit•this form within •30 days •of comple•tion of well
10.Static water level beloivtop of cnsiIIg: eonstniction to the following
1/'nwhr16•clisahrirec l be Ilse +" . . o ( ) •
.
•
Division of Water Resour ter,Information Processlug.Unit,
1 I.Borehole diameter:. t0 1617 Mail Service Center,l4aleigh,NC Z7699;1617 •
(In.) 24b.For-Iniection:Wellsi In addition to sending the form to the address in 24a
12.'Well construction Method: 4 ► u�� above,e, also to the one copy of-this foim-within 30 days of completioq of well.
(i.e.auger,tutor•,cable;direct push.etc.) • construction to the following:
POR'iVA,:I;'sa SUPPLI''fh'RLLS ONLY:•
Division of Water Resources,Underg
round Injection Control Program,
1636 Mail:Serbice Center,Raleigh,NC27699-1636
13a.Y?cId((;pill) .3 Method of test: • ' '
24c:For Water SUimly&'In eetion'Wells; In addition to•sending the foam to
13b.111sinicction type: the.address(es) above; also submit one copy of this.form within 30'days'of
Amount:J rr; Q Z completion of well construction to the county health department of the county
where constructed.
Fcir,:i OW-! North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016