GW1--03467_Well Construction - GW1_20240611

FELL CONSTRUCTION RECORD GW-I
1.Well Contractor Information: For Internal Use Only:
Chris King
Well Contractor Name 14.WATER ZONES
FRONI r DESCRIPTION
2080-A
r
NC Well Contractor Certification Nwnhei �. �®
Aqua Drill, Inc. 15.OUTER CASING for multiaased wells OR LINER If ie
.Rcab
Company Name �� DIAMETER THICKNESS IMMEIMMENE
l ' in.
ingEMIMIIMM
it#: ��L 7 _P S 16 INNER CASING OR TUBING(_eatherrnal closed ton,
2.Well Construction Perm
List all applicable well c wcernretion permits(i.e.WC Count ® ft..State,Variance.etc.) FROM TO DIAMETER
THICKNESS
in. MEN
3.Well Use(check well use):
Water Supply Well: ® in. —
17.SCREEN
�:1a�Iicultural DMuitctpal/Public •
FROM TO DIAMETER SLOT SIZE
ft. D. in. MATERIAL
�Geothermal(Heating Cooling Supply) —
,�.ltcsidcntial Water Supply(sanale)
1111 Industrial,Commercial DRcsidenttal Water Supply ft D 1°' —
PPY(shared)
18 GROUT —
Non-Water Supply Well: FROM TO MATERIAL Em....ME\T METHOD t AMOUNT
it U ft. D.Monitoring ,`I _ ,
Injection Well:
,'Recovery ft
ft.
�1Aquitcr Recharge Groundwater Remediation
ft. D•
,II Aquifer Storage and Recovery OSaltnity Barrier
19.SAND/GRAVEL PACK if a.dicable uniminim-
■'AguiferTest FROM To MATERt.tl.
OStormwater Drainage F.\IPLACFNIF•\l'PIFTHOD
ft. ft.
a Experimental Technology lSubsidencc Control ® _
)r Geothermal(Closed Loop) Tracer ft.
Geothermal I leatina%' 20.DRILLING LOG(attach additional sleets if necessan
( Cooling Return) "':Other(ex)lain under t) FROM To
I Remarks) DESCRIPTION color,hardness,soil/rock Is se... c.)
in size.et
J ft. D.
4.Date Wells)Completed, yWell ID# e .4
Sa.Well Location:
I-
Facility Chun:Name �—
Facility IDtl(ifapplicahlc)
? �r �Pt�hF
Physical AJdnxs.City,and Zip 111 r
,� a$r3 D. ft. ,
n 21.REMARKS
County
•
Parcel Identification No.(PIN) lr orlrieyern r er;_r, e: I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(if well field.one IaPlong is sufficient) ___
22.Certification:
W
6.Is(are)Inc well(s) permanent or C6Temporan I nature of lric?Wc)jCwuac:o ) ��CJ -2 V v��\ Uoc
7.IS this a repz:;to an CXlatjlt tp By signing this.firur,I herchv rerrifi,Ilea the I rdl(s)psis(nrrr/ronxaaried in arcor,Mnce
g cll: 0Yes or No with 1SA:VCAC 02C'0/00 nr 15.4 NC4C 02C 3200 Well Construction Stan/ands and that a
I[i/ii is a repair.fill nal knout srr//ranmrnuriion ipftn•muritu,ant avpiuin the nano•:of the Cali).WOW:Petwd hum heea pros>ldwl is she well owner.
repair antler c21 remarks scrtlnn nr an the hack t f lltls fort
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same 23.Site diagramfagranl oradditional well details:
You mayuse the back of this page to provide additional well site details or well
constnict'.o.:.only I OW-I is needed. Indicate TOTAL NUMBER of wells
drilled: _ _ construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 3,2SUBMITTAL INSTRUCTIONS
Fw multiple wolfs list all depthsgt/ihctear(example-31ti200'wad 2Q.1(py) (ft.) 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 casing: Q
Ifs+aver level is above casing,use.. l.� (ft.) Division of Water Resources,Information Processing Unit,
6 1617 Mail Service Center,Raleigh.NC 27699-1617
1 I.Borehole diameter: (in.)
�J 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Weil construction method: 4//2 G"/r;f above, also submit one copy of this form within 30 days of completion of well
(Le.auger.rotary.cable,direct push.etc.) construction to the following
Division of Water Resources,Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh.NC 27699-1636
13a'Y'.eld(;Fn) Method of test: 19 h + 24c.For Water SupDly& Injection Well.: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
fe
13b.Disinctio:)Tpe: )7 rj-/ Amount: I Id C Z completion of well construction to the county health departinent of the county
where constructed.
Form C,4\ North(•arolten Department of Environmental uali
Q ry-Division of Water ResourcesRevised 2-22-2016