GW1--04566_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
: I---7—
I.Well Contractor Information:
Chris King _
14.WATER ZONES
Well Contractor same FROM TO DESCRIPTION
2080-A A6 0 ft. 61 ft. 3 i'/r"1
ft. rt.
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS I iSrERiAL
(F" ft. �
Company NameC ] ft. 1 6 yLl in. l 547-> i )
izz r j :v r C
is INNER CASING OR TUBING(geothermal elosed-loop)
2.Well Construction Permit#:CA....)2 Cl - (•c I q FROM TO DIAMETER THICKNESS MATERIAL
List all applicable tell construction permits(i.e.UIC.County.State. Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in,
Water Supply Well: 17.SCREEN
AgriculturalFROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
0Municipal/Public ft. I ft. in.
Geothermal(Heating/Cooling Supply) 1114k.esidential Water Supply PP Y(single) ft. ft. in. I
Industrial/Commercial E)Rcsidential Water Supply(shared) i ! I
18.GROUT
•Irrigation FROM TO MATEFIAL EMPLACEMENT METHOD&i5IOUNT
Non-Water Supply Well: Ft A C°. ft. JL'11173Ni c
� K
!Monitoring �Recovery 4�;
ft. ft.
Igjection Well:
Aquifer Recharge OGroundwater Remediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL 1
EMPLACEMENT METHOD
Aquifer Test DStonnwater Drainage ft. ft.
Experimental Technology 'Subsidence Control ft. ft.
Geothermal(Closed Loop) i Tracer
20.DRILLING LOG(attach additional sheets if necessary)FROM TO DESCRIPTION(color,hardness,soil rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
ft. C ft. Sc. ' '
4.Date Well(s)Completed:7 1�1 - Well ID# 6 ft. 1 IS ft. 6 n�✓ci j2U L K
5a.Well Location: )g ft. 5 5—ft. 73)_, e &`n 1'4 C
ft. ft.
Facility/Owner Name Facility ID#i fapplicable) ft. ft. 7 lA' f� �,�
3537 kodgc S Ti` l C.h4)pei 11i)� ft. ft. JI�� v t 11i,I
Physical Address,City,and Zip ft. ft.
�Z/4 Q
County / 21.REMARKS — m
Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees: i
(if well field.one lat'long is sufficient)
22.Certi6 lion:
N W
6.(stare)the well(s ermanent or Temporary Signature of Certified Well Contracto _/
Date l
Br signing this form.i hereby certi5'that the well(s) ova(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or t No nvlh iSA NCAC 02C 0100 or ISA NCAC 02C 020/)Well Construction Standard,and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks.section or sin the hack of this hurt.
23.Site diagram or additional well details:
R.For Geoprobe/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
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary
drilled:
�--� SL'BNIITTAL INSTRUCTIONS
J
9.Total well depth below land surface: lfW 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-301200"and 2(10001
/1 construction to the following:
10.Static water level below top of casing: (� 0 (ft.) Division of Water Resources,information Processing Unit,
if water level is above casing,use--,-
1617 Mail Service Center,Raleigh,NC 2 7699-1 6 1 7
11,Borehole diameter: 6 (in.)
24b. For injection Wells: in addition to sending the form to the address in 24a
12.Well construction method: r/j`rl-- A)Z l ) ' above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push.etc.) constriction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: 7)rein"t 24c. For Water Supply& Iniection Wells: In addition to sending the form to
f the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Tf Amount:/ 7 8 t completion of well constriction to the county health department of the county
where constructed.
Form GW-I North Carolina Depmtmenl of Environmental Quality-Division of Water Resources
Revised___2-22-�_Olfi

iii IP .
HEALTH DEPARTMENT
•N'wing health I.ipirinc change
ORANGE COUNTY ENVIRONMENTAL HEALTH SERVICES DIVI
SION
ONSITE WATER PROTECTION SECTION
REQUEST FOR USE OF THERMOPLASTIC CASING TO CONSTRUCT A WATER SUPPL EL
Y WL
Property Address: S j 7 A CSC:.
a C'� ")t ) i ) ) W C
Well Contractor Name -
L• uC" OCHD Well Permit#: W,Z(1 23
Contractor Registration NaaC, "
Property PIN:
REASON(S) FOR INSTALLING THERMOPLASTIC CASING:
1.
2. —
3. —
4. —
5. —
Well Owner Name: 616/144
_2________________
Well Owner Signature: 1.14-1/14t
•
Date:11 / Ll.�
Well Contractor Signature: - 17 e - ►
Date 2/ 21-1
919 245 2360 v 131 West Margaret Lane, Suite 100 ). Hillsborough, NC 27278 orangecountync.gov