GW1--03037_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.7-
1.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A ft. - ft. o G l Ni r1 //ss
ft. ft
NC Well Contractor Certification Number
15.OUTER CASING(for multi•casedwells)OR LINER(if ap licable)
M
Aqua Drill, Inc. FROMTO DIAETEP: THICKNESS MATERIAL
Company Name 0ft. • %z ft. / i/C j im 5p JZ2`/ I Pi�: C
16.INNER CASING OR TUBING geothermal dosed-loop)
2.Well Construction Permit(4• ?J 2 -00 Cl2GFROM TO DIAMETER THICKNESS MATERIAL
List all applicable well canstow•tiot,permits ae.U/C.County.State.Variance.etc.) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN _
A Cultural FROM TO DIAMETER_ SLOT SIZE THICKNESS MATERIAL
0Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) ifffiesidcntial Water Supply(single) ft. R. in.
IndustrialiCommcrcial �(Residential Water Supply
pl y(shared) 18.GROUT
liTigat1(rtl FROM TO MATERIAL EMPLACEMENT METHOD&.MIOUNT
Non-Water Supply Well: © ft. oCC) ft. CCM iafQ 4 6 Tau c.K$
Monitoring DRecovery ft. ft.
Injection Well:
QAquiter Recharge Groundwater Remediation ft. ft.
A uifer and Recove 19.SAND/GRAVEL PACK(if applic able) -
q Storage ry jSalinity Barrier FROM TO MATERAAI. EMPLACEMENT METHOD
DAquifer Test QStormwater Drainage ft. ft.
DExperimental Technology QSubsidencc Control ft. ft.
1:3Geothennal(Closed Loop) E Tracer 20 DRILLING LOG(attach additional sheets if necessary)
OGeothemlal(I leafing/Cooling Return) r7lOther(explain under#21 Remarks) FROM To DESCRIPTION(color,Lanlacss soil/rock type,grain nee,etc.)
0 ft. 6 ft, ,ZCci C;p. y
4.Date Well(s)Completed: I -12 -4.`/ Well 1D# (' ft. 25 - ft. 5Asj,a Roc - r-„u d
5a.Weil Location: ft,
75- 6 (i.SIL .1)/mac_ 6ri14ri a•4-C
ft. ft.
Facility Ow0..-Name Facility!Mt(ifapplicable) ft. ft.
3 / /��yieo ,r� ft. ft.
Physical Address,City,and Zip %7e 4Q S- ft. ft.
V i 11="d 2LI 21.REMARKS
County Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat'Iong is sufficient)
22.Certification:
N W
y•- 12- Y
6.Is(are)the well(s) rmancnt or jTemporarS Signatureof CAntificd Wdl Contra or Date
Br signing this•hu nt,I hereby ceriijt•that lire well(s)was(iwere/eons/meted in ucti rhuce
7.Is this a repC.r to an existing well: DYes or agNo with i5A NOW 02C.0100 or 15.4 NC.4C 02C.0200 Well Construction Standards•and that a
If ibis is a repair.fill nut kiln,rn we/I e1111.thIleliMI in/inmaliatr and crplaiu the nation,rif the cnpr of this record ltos heen porn idcd in the well owner
repute tinder tr11 remarks Avian rue on the hark nfthis frrn•m.
23.Site diagram or additional well details:
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same Youmay use the back of this page to provide additional well site details or well
constructio::.only I OW-I 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: 6 (ft.)
For nndlipl,:mils list ull depths ifdijjereni(ramp/e-3(4200•and?(u{100') 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of easing: 6 0 (ft.) Division of Water Resources,information Processing Unit,
If miter level is above easing.use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (In.)
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Weil construction method ��il'IZ d j�; above, also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR ttdls IaL SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Program,
C 1_ 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.:'?,^!e!( pn:) Method of test: J,q ki T . Wh• ectiouaddition sending
r / the24c address(esForater) aboveSupp, al&inlso submit oWells: In ne copy of
add this form to within 30the days oform tof si..13b.Diti�ctitnr type: H Amount: /`j 0 Z completion of well construction to the county health depamnent of the county
where constructed.
ion:,aw-: N�„i, n,.........,.... -