GW1--05683_Well Construction - GW1_20240920

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WIE]LIL CONSTRUCTION ,',IECO i"'l' (GW-11 For Internal Use Only:
1.Well Contractor information:
Chris King 14.WATER ZONES
Well Contractor Name �FROM TO DESCRIPTION
. 2080-A �-"I c ft. 6,/ ft. )J i C I p(
ft. iii�G ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. (1:3 ft. /Y Y�in. 5 ia i/ 1�(, Jr c,��a' 16.INNER CASING OR TUBING(geothermal closed-loop) 1 v
2.Well Construction Permit/ J) 4
,t I - v o 3 Z. FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C•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 THICKNESS MATERIAL
Agricultural ®MunicipaUPublic ft. ft. in.
Gcothcmmal(Heating/Cooling Supply) csidcntial Water Supply(single) ft. R. in.
IndustrialiCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: IL ej ® .ft. ti cio-6'f'Ii7C' C I'1 c p $
Monitoring °Recovery ft. ft.
Injection'Well:
ft. ft.
Aquifer Recharge EGroundwater Remediation
Aquifer Storage and Recovery V�{Salini Ranier 19.SAND/GRAVEL PACK(if applicable)
P tyFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
i Geothermal(Closed Loop) ij'Tracer 20.DRILLING LOG(attach additional sheets if necessary)
'„ FROM TO DESCRIPTION(color,hardness•soi/raek type,grain size,etc.)
_:Geothenmal(Heating/Cooling Return) 1:iiOther(explain under#21 Remarks) O ft. / ft. so,6 l
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4.Date Wells)Completed:1 '34`-' , 7 Well ID# G ft. 5-5- ft. S A IQ 8 0 0 C it
5a.Well Location: —S' ft• .nor°r". 6�k6 c -ti1V 17 C
ft. ft.
Facility'Owt:::Name Facility TM(if applicable) ft. ft. ,
/� G- • • ^s1i ^� r
2O 2D WNICe•% }1% f) i r i i re ,C ft. ft. a ;a.-ee..h t...i./!,...'
Physical Address,City,and Zip7 ft. ft.
OY Y 1�7 d� ' SFP 2 � `fl?A _
R�I v& 21.REMARKS
,County Parcel Identification No,(PIN) li',sC„ti•6.: ?fr•r'J .M1 t l-C:>t•-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.
(if well field.one fat/long is sufficient) 22.Certific lion:
6.Is(are)me weli(s) -ermanent or DTemporary Signature of Certified Well Contractor Dam
Si'signing this Arm.I hereby cenif that the well(s)was(were)c•onstrruted In accordance
7.Is this a repair to an existing well: ° 'es or!> No with ISA NCAC 02C.0100 or iSA NCAC 02C.0200 Well Cnnstruciinn Standards and that a
If this is a r✓pair,•/Nl ma know,well t•ateu•nc•aa,h fuinauinu and ctplain the nature gfthe capr r fib/s record has been provided to the well owner.
repair tinder,21 remarks set•iion or an the hark cur this farm.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the same
consttuctio only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
5._ SUBMITTAL INSTRUCTIONS
9.Total will depth below land surface: (ft•) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wr/ds list all depths ifdyrent(crumple-3rd 200'and 2;m100') • construction to the following:
10.Static water level below top of casing: CQ D (ft.) Division of Water Resources Information Processing Unit,
If water lets!is chore casing. '+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For inlcction Wells: In addition to sending the form to the address in 24a
CY�i/ ! above,also submit one copy of this form within 30 days of completion of well
12.Weil construction method: /� construction to the following:
(i.e.auger.unary,cable,dimes push•etc.)
• Division of Water Resources,Underground Injection Control Program,
FQR Vir.....rea SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a..'al:?(„pre) � Method of test: �'{�(jf Li 4- 24c.For Water SIMIAN I&infection'Wells: In addition to sending the form to
/ the addtcss(es) above, also submit'one copy of this form within 30 days of
136.i~"isi.^::cretins`.ppe: ��� �-� Amount: /. ©"?"-- completion of well construction to the county health department of the county
where constructed.
Fona GW-: North Carolina Department of Environmental Quality-Division of Water Resources : Revised 2-22-2016