GW1--05458_Well Construction - GW1_20240912

WELL CONSTRUCTION"RECO':I1' (OW-)1) For Internal Use Only:
1.Well Contractor Information:
Chris King 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name )16 ft. 9 C rt. !er i pt r i
. 2080-A L f1. f ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap !feeble)
Aqua Drill, Inc. FROMy TO DIAMETER T� .X. 6CIICtSS, MATERIAL
/'j - /
fL C'2 fft. 6, iyi in. f -4 1 V
Company Name aa rXEy� A i S 16.INNER CASING OR TUBING(geothermal closed400p)
2.Well Construction Permit#: O 3 kJ l�L_r J:4 I FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable veil construct ma permits(i.e.UIC'.County.State.Variance.etc.) ft. ft. i in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNFSS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 611.esidential Water Supply(single) ft. ft. in.
Industrial/Commercial DRcsidential Water Supply(shared) l8.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
Non-Water Supply Well: 0tt. t O ft. �c�', j4Ni-4e aPo i es'
Monitoring DRecovery ft. R.
injection Well: ft. fr.
Aquifer Recharge 0 Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery JSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology ()Subsidence Control ft. I ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness.soil/roelc type.grain sire.etc.)
�Geothertnal(Heating/Cooling Return) II^110ther(explain under it21 Remarks) ft. 3 ft. )2 _8 Chi
/
4.Date Well(s)Completed: 44 7,16 0}C(Well 1D# L • - ai.C. 3 ft. ft. 5il Rock
5a.Well Location: 3S-ft. 3aS-ft. f1 k�iu c I& AA-IC
ft. ft.
Facility'Ow::ce Name /� Facility ID#(if applicable) ft. ft. P-^
�/ 'nel:,
o27 virvc oAr5 gCI ft. ft. s®`P. A"#e/ "
Physical Address.City.and Zip ft. ft. e...LO
111Api)4� e 21.REMARKS sLi 1 2 /I1/4
County Parcel identification No.(PIN) Ir ..-w• :: ��y,
-�- .-f`,• ,�:..o':-CiiNd,p unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��'fi" _',
(if well field.one latilong is sufficient) 22.Certification'
N W e.%4 , 4 •- Cg-..2 C"2 `"(
6.Is(are) me evell(s) manent or Temporary Signature of Certified Well Contractor) Date
By signing this Arm.I hereby cvrtifi'that the well(s)was(were,rnnsmut•ted in accordance
7.Is this r:rTV::i to an existing well: 0Yes or axo with NSA NC1C 02C.0100 or 1SA NCAC 02C.0200 Well Constntnimt Standards and teat a
((this is tt:epair...fll out knnutit well caavtruction i f,rnmtion and explain the nature ofrhe eopr tf(his retard has been provided 10 the well owner.
repair under 1121 remarks section or an the back of this foray. 23.Site diagram or additional well details:
8.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
constntcti02.only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:_ r SUBMITTAL INSTRUCTIONS9.Total well depth below land surface: `� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple::ells llst all depths ifdi(jercnr(example-aid 200'and 271,100') construction to the following:
10.Stark water level below top of casing: `'` (ft.) Division of Water Resources,Information Processing Unit,
if water fere/is(hove casino.use +- 1617 Mail Service Center,Raleigh,NC 27699-1617
It Borehole diameter: '`'" (In.) 24b.For injection)'Dells: in addition to sending the form to the address in 24a
/l '' J 'I I I above,also submit one copy of this form within 30 days of completion of well
I2.Weil etlemstrucrion method: f-i C: construction to the following.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FO i r'''li:B.SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Vick/(„pi::) 1 Method of test: . 1 ci)'- 24c.For Water Supply&Injection Wells: In addition to sending the form to
/ the address(es) above, also submit one copy of this form within 30 days of
13b.Dian:ce!ien`)•pe: /4T1"1 Amount: 16 0 completion of well construction to the county health department of the county
where constructed.
Form GIG-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016