GW1--03051_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD GW-i
1.Well Contractor Information: For internal Use Only
Chris King
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION 2080-A 90 R• 9! R.
NC Well Contractor Certification Number , '/1�
4. fr. ;11121.5I rl.Aqua Drill, Inc. �"y'IS.OUTERSING for multi-cased wefts OR LINER tf a Ilcable)
FROM O DIAMETER
Company Name �>•IATERIALfl. • in.3��6J �; Sv.Z ,
2.Well Construction Permit#: 16.INNER CASING OR TUBING(,eotherrnal closed-loo L 'List all applicable well construction permits(i.e.UIC.Cototttt Slake Variance,era) FROM ft. TO DIAMETER THICiGVFSS
MATERIAL
3.Well Use(check well use): ft in.
D. n in.
Water Supply Well:
17.SCREEN —
Agricuilural FROM TO DIAMETER SLOTSiZE THICKNESS
Vtmticipal/PublICMATERIAL
j♦'Gcothemtal(Heating/Coolin Supply) ft. ft. in.'-
g p! y) t�8esidential Water Supply(single)
1♦,IndustriahCommcreial ft.j R. in —
OResidential Water Supply(shared)
AVM•anion 18.GROUT —
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
C� ft. . a ff. 1�
:Monitoring ..l..ibl 1� �If�
Injection Well: "Recovery R.
ft.
Aquifer Recharge Groundwater R ft. R. —
:Aquifer Storageemediation
and Recovery Salinity Barrier 19.SAND/GRAVELPACK if a••licsdle
FROM TO MATERIAL Drainage R, EMPLACEMENT METHOD
Experimental Technology R.
Subsidence Control R
*Geothermal(Closed Loop) R
1Tracer 20.DRILLING LOG(attach additional sheets if necessary
_ Geothermal(Heating/Coolin Return) iOthef(ex,lain under ik2 1 Remarks) EOM TO DFScrTI JA(co tor,hardncsz,saiUroek ti.ae. sin size ere.)
40 ft. R. -j6o/ —
4.Date Well(s)Completed:3-�6-" _
Well ID# ft. R.
5a.Well'Location: _ G
C `ft.
6 4v fr. ft.
Facility'Owner Moore
Facility IDti(ifappIicablc) ft. ft.
r3 i j h ni C ft. R —Physical Address,C.
and Lip ;� i R
ft. ff. —
.63 5
21.REMARKS
County _
Parcel Identification No.(PiN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well tick'.one laalong is sufficient) —
22.Certification:
w
6.Is(are)sore well(s permanent or DTcmpo'ary at ire of'Certified cll Contra for 1 fate
e
7.Is this a rep£r to an existing well: Dyes By.cigoing this•Juno./hereby milli'that the WOO)nrec
IT this is a rmair,,Jill ni known well anas6'msitin i ft ' uthm and a plant he mine of Mc r tANo 11 th/fll&record has nheen 100 pmwdm/In he u+ellT'�Vie!!Construction�rclionre) t Slutathftn/r ann d tharcu
repair under H2I remarks section or um the bark of this fluor,, copy
l well details.:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23'Site diagramathe back of thisapage to provide additional well site details or well
constn:clin::,only I OW-I is needed. Indicate TOT You may
drilled: NU�tDER of wells constriction details. You may also attach additional pages if necessary.
9.Total well below land surface: a LiS— SUBMITTAL INSTRUCTIONS
For tnnh/p/r:re lot u/l depths if different/ermup/c.3r(a300'and-'(a'//Xll) (R') 24a. For All Wells: Submit this form within 30 days of completion of well
10.State water level top of casing: 6 0construction to the following:
/luturr/err/is«hoia el below.Ow +^ (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter. 4 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Injection Wells: in addition to sending the form to the address in 24a
12.Weii construction method: �) 2 I above, also submit one copy of this form within 30 days of completion of well
(i.e.auger.rutin',cable,direct push.etc.) construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR iVa;Lrc SUPPLY WELLS O:�'Y Y:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Vick!( pm) Method of test:_51 '
24c.For Water Supply& injection Wells: In addition to sending the form to
13b.sisirticxeicu 1 ne: / O the addresses) above, also submit one copy of this form within 30 days of
Ark_ Amount completion of well construction to the county health department of the county
where constructed.
Pane OW-I
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