GW1--05678_Well Construction - GW1_20240920

WILL(CONSTRUCTION RECORD(GW-11 For Internal Use Only:
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1.Well Contractor information:
Chris King 14.WATER ZONES ,
Well Contractor Name FROM TO DESCRIPTION
. 2080-A 90 ft. 93 ft. 10 '(.1!°t M
NC Well Contractor Certification Number 13G1 ft. /3; ft. /CY L f g,lm
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM To DIAMETER THICKNESS MATERIALj
Company Name 0 ft tad.6 ft. 6 y4 in. SDiz 21 1 i ti,c
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�J 0p� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit 1 dO 9B 00007 j`J FROM TO DIAMETER THICKNESS MATERIAL -
List all applicable well construction permits(i.e.UIC,Comae.State,Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural al/Public Munici
®� P ft. ft. in.
DGcotitcnnal(Heating/Cooling Supply) of esidcntial Watcr Supply(single) ft. it. m in.
Industrial/Commercial jRcsidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V ft. � ft. �,, ,i
Monitoring �7r�v-�1111}t° �'d 1
DRecovery ft. R.
Injection Weil:
ft. ft.
Aquifer Recharge 'Groundwater Remediation
_Aquifer Storage and Recovery OSalinityBarrier 19.SAND/GRAVELPACK(if applicable)
FROM TO MATERIAL. F.NiPI)PLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. R•
Experimental Technology Subsidence Control R. ft.
Geothermal(Closed Loop) Tracer • 20.DRILLING LOG(attach additional sheets if necessaryil )
GCOthCnnal Heating Coolie Return) FROM TO DESCRIPTION(color.hardness.saiaraNe tsnc,gain size.etc.)
( g/ gg 171Othcr(explain under#_1 Remarks) O R ft-
5�
4.Date Well(s)Completed: '6 -- 2ci Well iD# 6 ft. +10 ft. 5 AN 8 jZ6 Ck
5a.Well Location: p d ft. Ji 5 ft. 13 i ve 6-a niv 4 C.
ft. ft.
Fnrility'Otv::er Name Facility ID0(if applicable) ft. ft. F. I',
,4S`--`-1 LCO iC CoJ)i C?2. 2C1 j..., r m i-r:Nf C ft. IL
S E P ® "elf d s
Physical Address,City,and Zip ft. ft.
AWN 'oL jj/ 21.REMARKS
Irf:;:r:.ri.0 c j)rr.r.iAe".s I,;7::z
County Parcel Identification No.(PIN) .�. . .._., .
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Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one iatilong is sufficient) 22.Certific tion:
N Wç °16.Is(are)the weh(s) rmanent or QTemporary Signatu ofCcniticd Well C Date
Br signing Otis firm.1 hereby certify that the nm/!(.$)was(were)constructed in acconlance
7.Is tall:a regal to an existing well: Ogres or igdzio with 15.4 MI 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a n ptir,•liil era know,well construction b f irnmtimr and etplain the nature of the copy of this record has been provided to the well awne,
repair under a21 remarks section or on the hack of firm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/3DP I or Closed-Loop Geothermal Wells having the same
constr!ctkt.,only 1 OW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
i S SUBMITTAL AI INSTRUCTIONS
eje
9.Total vc13 depth below land surface: 5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiljercnt(example-3t)200'and 2;do100') construction to the following:
10.State water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
If water Ie t e!it abate rasing,use '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
12.Wail ea:;strut lion method: L I i 7 d jzj , above,also submit one copy of this form within 30 days of completion of well
(i.e.auger.rotary,cable,direct push,etc.)
construction to the following:
Division of Water Resources;Underground Injection Control Program,
FOR.V•iA3 i ii:SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.?laid(awn) r),0 Method of test: S t I 11 24c.For Water Simply&injection Wells: In addition to sending the form to
d �� the addresses) above, also subinii one copy of this form within 30 days of
13b.Dlsin ecti n:ype: l�T/4 Amount: completion of well construction tol the county health department of the county
where constructed.
Form G14-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-U0I A