GW1--05866_Well Construction - GW1_20241001

WELL CONSTRUCTION RECOi', i (IGW-1) For internal Use Only: ""7-
1.Well Contractor Information:
Chris King i 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2080-A c2 30fl, 01'�' ft. `} 1!n,r,
n. 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 st TERIAL
Company Name tJ ft. 0 ft. ( l/ in. C'i\R f 1 Li tC
O2 3 ��,q� 7� 16.INNER CASING OR TUBING(geothermal closed-loop)
1
2,Well Construction Permit CI r FROM TO DIAMETER THICKNESS MATERIAL
Lisa all applicable well construction permits(i.e.U!C.County.State. Variance,eti. ft. n, ! in.
3.Well Use(check well use): ft. ft. I in.
Water Supply Well: 17.SCREEN
A icultural FROM TO DIAMETER SLOT SIZE THICKNESS t MATERIAL
OMunicipal/1 ublic I ft. ft. in.
®Geothermal(Heating Cooling Supply) ORcsidential Water Supply(single)
ft. R. In. .
Industrial.'Connnerctal ®Residential Water Supply(shared)
13.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT SIETIIOD&ANOINT
Non-Water Supply Well: ' ft, ' �' R, ���� C` rPS
Monitoring �Rccovcry n, ft. LI
Injection Well:
Aquifer Recharge• n' D•
�Groundwatcr Remediation
Aquifer Storage and Recoveryt9.SAND/GRAVEL PACK(if applicable)
$ahnity Ban-ter FROM TO MATERIAL, F•MPIACF.MF.NT METHOD
Aquifer Test Stormwater Drainage ft. ft.
Experimental Technology OSubsidencc Control it. ft.
Geurhen al(Closed Loop) Tracer 120.DRILLING LOG(attach additional sheets if necessary)
a3Crcothem al(Heating/Cooling Return) (Mier(explain under tt21 Remarks) FROM TO DFSCRIPTI(QN(color.hardness.soil/ruck hype.grain ate.de.)
�-y-� �, ft. ft. 1 CCI C 1 i9 .
i.Date Well(s)Completed: Well ID# �, ft. 1, ft. ,1) C( J o C t-
Ss.Well Location: A C ft. O' 'ft. /3/vc- t!_ ,,14 C
'3rFF -e y iv.jXO, ft. ft.
Facility(3w::xr Name Pao lily tOn(if applicable) I ft. f.
3. o C�h;4,-s 01,,,rzi» ► czd ft. ft. 7,.,a
.��. '� _
Ph ical Address,City,and Zip Fg��l r IN(i) J J e j1J+C ft. ft. C Z 2024
I�} O J f + r 1 121.REMARKS
County ru, I it. �.;;x,.. :: ,'•-,.:✓,-:'-,+y _••l
Parcel Identification No.(PiN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well lick).oin:at long is sufficient)
22.Certifl lion:
N W / r 9- `'— 9
6.ls(are)t:te weh(s m ranent or IJTemporal•y. Signature of Certified 'ell Con for D11e
Br signing this form,I hereby eeriir•that tie ne//(s)was(were,runsirucied In accordant'
7.Is t i?s: re,��to an existing well: Wes or No with .....I :IC 02C.0i00 art ISA NCAC 02C 0200 Well Consinrrtion Standard,and tint a
If this is a,-.pair,lid out knuun well construction iitfatsiiaiian uric rrplain the nature(like corn.of ibis record has horn provided la the well nowt*
rtpuir under a 2!remarks'mY lion is on the buck of this fin,,.
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/DPT or Closed-Loop Geothermal Wells having the same
constncta. cnh I OW is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
`) SM— SUBMITTAL INSTRUCTIONS,
9.Total welldepth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple:tells list all depths ifdifferent(example-3ia.20U'anti 2-a IOW)
construction to the following:
10.Strife water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
II water le vet is above c n.+ing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1 fl.Botch ie diameter: (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well c..asirucrion method:pi 1 it (1 lb. 1 j construction to the following:
(i.e.auger.rote.'y,cable,direct puss,etc.)
Division of Water Resources,Underground injection Control Program,
F(Dit tVt�:;;,l St i PL't'WELLS(D k': 1636 Mail Service Center.Raleigh.NC 27699-1636
13a."°eta;:gp, ) �� Method of rest: 47)i C {1.T • 24e.For Water Sootily& Injection`yells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.?'_f.fee. a ::$n2: fi/ /4 Amount: )4, 6 Z completion of well construction to the county health department of the county
where constructed.
Form CV-: North Carolina Department of Environmental Quality-DIN ision of Water Resoarees Retisr,)--rt_wilt 6