GW1--05456_Well Construction - GW1_20240912

WELL CONSTRUCTION RECORD(GW4) For Internal Use Only: i , 1,........... „,„_.
1.Well Contractor Information:
Chris King
14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A 966 `JO I ft. //2 4-, /d'ii
ft. ft.
NC Well Contractor Certification Number
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
' FROM TO DIAMETER THICKNESS I MATERIAL
•Company Name ft. 56 it 6 /: in. t ' Cri4 1 /
P y� S1! ! D*� L✓
13 L061
_ 1 C 1 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: '�! -1 FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well con.Nrnctian permits(i.e.U/C.County.State.Variance,etc.) ft. ft. is
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
b 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Municipal/Public ft. H. in.
Geothermal(Heating/Cooling Supply) :csidRential Water Supply(single)
ft. R. in.
Industrial/Commercial DRcsidential Water Supply(shared)
hrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ,r,
Monitoring DRccovery CJ ft. /(' f. h pf i a �j ;7�
injection Well:
Cl. (J h /V !� ►l
BAquifer Recharge j-Groundwater Remediation ft. ft-
Aquifer Storage and Recovery Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer TestStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. R,
•
Geothen±:tt!(Closed Loop) Tracer FR20.DRILLING LOG(attach additional sheets if necessary)
Geothem:al(Heating/Cooling Return) 1i'1Othcr(explain under#21 Remarks) OM TO DESCRIPTION trntoyr,hardness soil/rock 4•pr,train sty etc.)
u 6 ft. 5-- ft. ge�% I xi l
4.Date Well(s)Completed:-6' O 2 Sf Well ID#l'O4" 6 S` l !n� y�
D- cis" ft. �>F-,�ef Ed.(ir
5a.Well Location: (,$ ft. 6.25-fL 13)ue gvlgiaN,t4 e
ft. ft.
FaciliIv'Ow:: Name - Facility IDe(if applicable) ft, ft.
E'� 1 lb c§u)e OielleS /Z ft. ft. I ®�'`.P L.'i :d �:m_Li
Physical Address,City,and Zip R. ft. F P ] 2 ?fl?4
/114ir1,1/vC( - 21,REtdAR[CS
County Parcel Identification No.(PIN) ,':Ua
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I�"cb'.a �v.9
(if well field.one iatIong is sufficient)
22.Certification:
T.
N `Y a - 8 I6.Is(are)toe tveli(s) ermanent or Temporary Signature of Ceni ed Well Contrite or Date
As:signing this ',w.I herrhr ccrrij'that the wra/(.c)tins(were)constructed In accordance
7.Is this a repair to an existing well: Q}'es or ONo with/SA NCAC 02C.0/00 or 15.4 NCAC 02C.0200 Well Consavrtinn Standards and that a
/l•tleis is a repo/;Jill out known well construction h jerntatina awl explain the nature of the copy rfthis record has been provided to the well owner.
repair under 421 remarks section or on the buck If this Arm.
23.Site diagram or additional well details:
3.For Geoprobe/DPI'or Closed-Loop Geothermal Wells having the same Yon may use the back of this page to provide additional well site details or well
constrtct:ct .only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total cell depth below land surface: G SUBMITTAL INSTRUCTIONS
For undtilar s c l/s list n/1 depths ifdi(Jercrn(crumple-3Ri 200'and 2,rr•l0oq (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Stack water level below top of casing: 6 0 (ft.) Division of Water Resources,Information Processing Unit,
If w'afa.kw!is above easing,use'•+••
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
a 24h.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: ' 12. d�Z.1l i f above,also submit one copy of this form within 30 days of completion of well
(i.e.auger.ratiwy.cable,direct push,etc.) construction to the following:
FOR'W.4:ilia.SUPPLY y' 'BLLS ONLY: - Division of Water Resources,Underground Injection Control Program, .
r� 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Y?eid(gpin) G— Method of test: 11401 yi 1- 24c,For Water Supply&Iniection Wells: In addition to sending the form to
L �� the addresstes) above, also submit one copy of this form within 30 days of
13b.Disindictica :ype: T ( Amount: completion of well construction to the county health department of the county
where constructed.
Fonn CM'-I North Carolina Department of Environmental(waits_rn,ar:,,,,...rum.... -•..._o-...... - .