GW1--03448_Well Construction - GW1_20240611

WELL CONSTRUCTION RECORD GW_]
I.Well Contractor Information: Fol illtcrnal Use Only:
Chris King
Well Contractor Name WATER CONES —
2080-A FROMTO DESCRIPTION
11® 16/ R. /f`�ir
`IC Well Comrador Certification Vlunhar —
Aqua drill, Inc. IS.OUTER CASIASING(for®ulti-ca:,ed wells OR LINER if...lkablel
FROM
Company Namn lifilnammalliME
5-�J II. F. /Ai in. EMIIIMMEN
� DIAMETER
2.Well Construction Permit#: Og V / ��© 16.INNER CASING OR TUBING Itothermal closed•Ion.
NIE
Lisra!/,+vplicnhln well cnn.rtrrmit t permits(i.e.U/C.C',1 Src- Variance.etc.) FROM TO
DIAMETER
3.Well Use(check well use): ft• In. =—.
Water Supply Well: in.
—
Agricultural 17.SCREEN FROM —
°MunicipaVPublic FRO TO DIAMETER SLOT SIZE
IIEMERMIgi
Geothermal(Hcating!Cooling Supply) A.asidrn6al Water Su 1 ft ft. It.
Industrial•Coatmcrcial pp Y(single) IIIIIIIIIIIIIIII
ORcsidcntial WatcrSu I ft' ft in.
(triaion pP Y(shared) 18,GROUT _
Non-Water Supply Well: r•Ronl
® MATERIAL EMPLACEMENT METHODS AMOUNT
MR 6;Monitoring
We R ����,��
Injection Well: „Recovery !! is 7y
'Aquifer Recharge I®® _
OGroundwa Barrier
Rentediation
_}Aquifer Storage and Recovery Salim, 9 + 19.SAND/GRAVEL PACK if a.•Ilcubh:
Aquit r Test tY arricr I FRO11
IIIIIIIIIIIIIIIIIIII
�Stormwater Drainage _a TO MATERIAL
i F.n1PI aCF.MF.NT METHOD
Experimental(ClosedTechn lop I®�
Subsidence Control
IGeothermal Loop)
Di TracerGeothermal(!lertine C'ooline Return 1 20.DRILLING LOG(attach addltionci s:teets if neeessan•
1 .iOther(ex vlain under i!21 Remarks) i FROM DCRIi9l.4'color.harda.vai
,, urorli I% c. rain,Ire.atc.l
4.Date Well(s)Completed z R, �edFS .• V
Sa.Well Location: TO rt. IMMII I�/ ��NILj r���K
.c A 41%)r r
Facility Ow•re:Name
IMI
��`� FucilitylDO(itapplicablc) ®® _
C..Ioo t y,AYeN' S ® • `' L
min-
Physual Address.City,and Zip O k'v Ai Z
�, iz ft. ®�� .
County - -
Parcel Ih:mification Nn (PIN)
Sb.Latitude and longitude in deal a.
ens/minutes/Of well hall sac lal'long is sufficient)d seconds or decimal degrees:
22.CertificaHnn:
N• W r
Date
6.Is(oa-c)lac wcll(s)4 permanent or Temporary -��/`�i SignatureofC'enili Well Contractor —��- _ l
7.Is this o r epE:r to an existing well: yes or NID By signing thisfen w./herein.certify that nit ,til(,)was(were,ran.q,urtc9/In accordance
If this ix a repair./UI ant know,nril rrtns,va•tla,iiJirrtaatirn,and elpIaio the ircoru•r of in, wily a/ibir reran'law lima prorrded,n Jm nxli wean
repair under e2!Iw, •/,r A:Wa n or an the hark alibis jrne with/1,1 A'C:aC 0?f.'.0100 or/JA,VC.iC VC 0200(ref!Cow•4urllnn Standard.,and that a
3•For Geoprohe/DpT or Closed-Loop Geothermal Wells havingthe name 23.Site diagram or additional well details:
donstmcl:o only I GW_1 is needed. Indicate You may tine the back of this page to provide additional well site details or well
drilled: __- — TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: �� SUBMITTAL INSTRUCTIONS
For multiple wells list all depths il'dy/ercnr(example-3ta?00 and?ra:100' (ft.)
24a. For All I Wells: Submit this form within 30 days of completion of well
10.10.Shame water level below top of casing: [: construction to the following:
tour,Static
r!is thole rasing use'p (ft.) Division of Water Resources,,Information Processing Unit,
I1.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699_I617
(in.)
12.Weil coasit'ucdon method: �) 246.For Injection Wells
above,also submit one copy In addition
form within 30 day the s of comple to the tions of well
(i.e,antler rotary.cable,direct push.etc.)
_ construction to the following:
FOR t.. `r,B SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
13a.!'_cld F m I 1636 Mail Service Center,Raleigh.NC 27699-1636
("p ) Method of test: 5 J 0IL
24c.For Water SunDty& Injection lie le: In addition to sending the form to
13b.>.` i•".:i- eda l yp_; T 1 / the address(es) above, also submit one copy of this form within 30 days of
Amount: - (- 4,.Z completion of well construction to the .aunty health department of the county
where constructed.
Fonn CiW.1
North Comlina Department ofEnvir,mnentol Quality-Division of Water Resources
Revised 2-22-20I6