GW1--03053_Well Construction - GW1_20240520

WELL CONSTRUCTION RECORD GW-1
For Internal Use Only: I
1.Well Contractor Information:
Chris King
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
2080-A )5 t' )60 R• /4 GI F.f.
NC Well Contractor Certification Number ft. R.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap Seattle)
FROM I TO DIAMETER THICKNESS I MATERIAL
Company Name O ft. et f( rt. 1///,/ in. fp e.2 I 11(
3 5- J 9 16.INNER CASING OR TUBING(geothermal closed-loop) NI `/!�
2.Well Constnlction Permit#: FROM TO
List all applicable tieeanrtnlction pennies(i.e.U/C,County.State.Variance,etc ft. DIANETEIt THICKNESS M.4TERL4L
R. in.
3.Well Use(check well use): R. D. in.
Water Supply Well: 17.SCREEN
Municipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural �
Geothermal(Heating Coolin Supply)I r' ft. ft. in.
o g i P Y) � .csidcntial Water Supply(single) � -
IndustriuLCommcroiul ft. R. in.
�Rcsidcntial Water Supply(shared)
lmgemion IS.GROUT
Non-Water Supply Well: FROM MATERIAL EMPLACEMENT METHOD AMOUNT
0MoniwringRecovery AI ft. • ilk7 t tva le e in il, S
injection Well: R. R. -
Aquifer Recharge 0Groundwater Remediation ft.
R.
Aquifer Storage and Recovery Salinity garner19.SAND/GRAVEL PACK(Ifapplicable) J
Aquifer Test FROMTO MATERIAL EMPLACEM ENT PIF.THOD
DStormwater Drainage R. ft.
Experimental Technology Subsidence Control ft.
ft.
Geothermal(Closed Loop) QTracer
.Geothermal(lieatine-Cooling Return) '.Other(explain under rt?1 Remarks) 20.DRILLING LOG(attach additional OsN(color,s ifhardness.
necessary)
' ®® DESCRIPTION h�ard�nen,soiVmck Icpe.grain sire,cte)
4.Date Well(s)Completed: - /Well iD# MI� C`. �'-�
'MIME SlAru 1Zr�c�5a.Well Location: q 5 R• o R / . e -`7 � J ft. C./;I<1YU 1
ft.
Facility Owner Nunc Facility ID#(if applicable) ft. ft.
'6`100 /44.0y ,,cc R.e Dsv;))C. ir0 , R. ft. IY 'L' 0 c
Physical Address.City,and Zip rt. It.
4:A.ts'U)\ 21.REMARKS
County Pored Identification No (PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r
(dwell field.use lat long is sufficient)
22.Certification:
N
6.Is(are)toe weH(s ermanent or OTemporars Signature ofCertifi Well tractor ate " /
t��� Date
7.Is this a r'epr._to an existing well: QYes or Br signing this jinni,i 6e,rhr scull)'Mat the.tr/,'(,•)�r s(were,constructed in accordance
If this is rt r yutir.fill mat known 11e f/Pcrostr,a'rinn io/nrmwuu,at `gain die man,of the with
of!big(irtru'd4C 'hete heeC l)pr,ickd"li c)url1 „a c 2C ONO Well Construction S/nndurlr and thus a
repair,ender:? cct t 1,rururke section or on the buck of this frra,
23.Site diagram or additional well details:
8.For(sscnprobe/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
constntctio::only I OW-1 is needed. Indicate TOTAL NUMBER of wells
--- - construction details. You may also attach additional pages ifnecessary.
drilled:
3�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:
Far mohip/e:,ills list all depths ifdtyrreut iexwnple-3trc2W'and 2:Q./W) (ft.) 24a. For All V Submitit this fo(Tn xithin 30days of completion of well
C construction to the f foollowing:
10.Static water level below top of casing: .4
IjMiter less!is whore ruling,use (ft) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-16I7
II.Borehole diameter: 6 (in.)
^^ 24b.For Injection Wells: in addition to sending the form to the address in 24a
12.Well ct nstruction method: �-/i t'r ,rj 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:
Division of Water Resources,Underground Injection Control Program.
FOR 1Vri"i cR SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh.NC 27699-I636
13a.;''.eld tgpm) J O Method of test: i ff�
T't G,n � 24c.For Water Supply Se Injection Wells: In addition to sending the form to
�-1� / // the address(as) above, also submit one copy of this form within 30 days of
13b.Disinfection!ype: / ' ! �' Amount: f Lz e) ' completion of well construction to the county health depanment of the county
where constructed.
Fora C;\\'-! North Carotuto Department of Environmental Quality-Division of Water Resoure s
Revised 2-32-20 I G