GW1--05768_Well Construction - GW1_20240926

WELL CONSTRUCTifON RECORD (CW-1) For Internal Use Only:
I.Well Contractor Information:
Chris King 14.WATER ZONES
Well Contractor hank FROM TO DESCRIPTION
2080-A yGift' c4671t' /5 6-1 t)i ri
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM •10 DIAMETER THICKNESS MATERIAL.
Company Name V 6ft. 6 ft. C /� in. S DI' `7
11
`� lb.INNER CASING OR TU BI NG�eothertnal closed-loop)
2.Well Construction Permit#:_39 i 3 3 t� FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable cell construction permits(i.e. U/C.County.State. Variance.etc.) ft. ft. ; in.
3.Well Use(check well use): n. ft. i in.
Water Supply Well: 17.SCREEN
. FROM TO DIAMETER SLOT SIZE THICKNESS f :MATERIAL
0Agricultural i Munch al/Public
�• P ft. ft. in.
®Geothermal(Heating Cooling Supply) 5Rcsidential Water Supply(single) IL ft. in.
0 Industrial,Commercial DRcstdcntial Water Supply(shared) I
1S.GROUT
I]i1T1gation FROM TO MATERIaI. s EMPLACEMENT METHOD&AMOCNT
Non-Water Supply Well: I C IL .. (.'! ft. 'h�,n)-lI+,Ui.� e h t 13 5
Monitoring ORccoscry It. ft. t'�
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
RAquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL. ' EMPLACEMENT METHOD
]Aquifer Test DStormwater Drainage ft. ft.
Experimental'technology �Subsidencc Control ft. ft. �
t
Geothen at(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
( I^l FROM I TO DESCRIPTION(color,hardness,soil/rock type.train size.etc.)Geothermal(Heating/Cooling Return) t_ Other(explain under#21 Remarks) •
+ c ft. r ft. so
E 1
t r,
4.Date Weil(s)Completed� -t� -2 1 Well ID# G
tr. 60 is'. �t)rL t.1 2 � k6C y
5a.Well Iaea:ior.: ( C ft. 9 R. L3)L_ L C a Ait) /. C
ft. ft.
Facility Gw::::•Name Facility ID)(ii applicable) \ ft. ft.
j o erCi 010C�4-14.1]ti ►Z J al —\a fJ 7 ft. ft. '' �J 1._,.
t
� 2 ?024
Physical Address.City.and Zip ft. ft. L P
J,O/`Zh Pi 21.REMARKS
9 tY,
County Parcel Identification No.(PIN)
5b.Lathuue and longitude in degrees/minutes/seconds or decimal degrees: I
(if well field.one at long is sufficient) 22.Certification:
::.a;vei;(sPermanent or Temporary' Signature of Centtied Well Contract r Date
6.Is(arei
Br signing this fnn.1 herchr venni.that the wr//(s)was((seri)constructed in accordance
7.Is t1Cc 1.:e,;.::to an existing well: j4tes or ONo with 15:).KGlC 024: 0/00 or 15A.NCAC 02C 0200 Well Construction Simmulate&and that a
If this ix a repair,Jiil ntn known well construction inhumation and et-plain the nature of the stirs'of this•reevrd has been provided is,the we•/I""'"es'
repair under e?i remarks section sir on the hark of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
Y.ForGeoprobe/DPT or Closed-Loop Geothermal Wells having the same
constructic.: c.nb'1 CW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: _
SUBMITTAL INSTRUCTIONS
CJ
9.Toro:vvcli depth below land surface: —1 42 (ft-) 24a. For All Wells: Submit this fonn within 30 days of completion of well
For multiple wells list all depths ifs/ilfirent(example-3(ce200.and''a 11)0'1
_ const uction to the following:
10.Stafic water Icv2l below top of casing: S 0 (ft.) Division of Water Resources,Information Processing'Unit,
If water lets''is above casing.use'p"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.lsoyc2,c1_e diameter: C? (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
,//�� 1 above, also submit one copy of this form within 30 days of completion of well
Weil eil e. /y....s,rueion method: 'Z IRl i I construction to the following:
(i.e.auger.mut.),cubic,direct pus'«.etc.)
Division of Water Resources,Underground Injection Control Program.
FOR VYPt'.r id St)?PLV WiELLS Oe,LV: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.`.=ela',gpe ) I C Method of test: 9 Y7-f- 24c. For Water Supply& iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Dsir.::::i1::r `vice: 14T 14 Amount: )Cr I completion of well construction to the county health department of the county
where constructed.
Form C'sV-: North Carolina Depaninent of Environmental Quality-Division of Water Resources Revised 2-22-2011,