_Well Construction - GW1_20230310 (52)

WELD CONSTRUCTION RECORD(GW Y) III For Internal Use Only-
I.-Well Contractor Information:
David Belcher MWATERZONES
Well Contractor Name FROM TO DESCREMON
4�594-A 40 ft. _n ft
ft IL
NC Well Contractor Certification Number 15.OUTER CASING for mulfi cased wells OR LINER if a livable
Aqua Drill, Inc. FROM 70 �DIAMETER TnrcKNEss MATERlnL
Company Name 0 ft ft in. U
n` �/ 16.INNER CASING OR TUBING rm eotheal closed-loop)
2.We11 Construction Permit#: 'Q66/ FROM TO DIAMETER THCKNESs I MATERIAL
List all applicable tvell construction permits(e_UIC,County,State.Variance,etc) ft ft. In.
3.Well Use(checkwell use): [t fL in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOT SITE THICKNESS MATERIAL
Agricultural unicipal/Public ft ft. ;n
_.Geothermal(Heating/cooling Supply) a_ Re1id,,ti,1 Water Supply(single) ft. id— in.
1ndusttiallCommeric1d [31tesidential Water Supply(shared) 18.GROUT
hri ation FROM t TO MATERIAL EMPLACEMENTMETHOD&AMOUNr
Non-Water Supply Well: 0
ft.
fit
Monitoring Recovery ft ft
Injection Well:
Aquifer Recharge OGroundwater Remediation fit fit
19.SAND/GRAVEL PACK if livable
Aquifer Storage and Recovery Salinity Barrier FROM I TO I MATERIAL I EMPLACEMENT METHOD
3AquifierTest ElStormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
:Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necess
Geothermal(11-ting/Cooling Return) nOthcr(explain under#21 Remarks) FROM TO DESCRIMON color,hardness,suilhock type,grain etc.)
0 It.
0 IL
nav
4.Date Well(s)Completed: .3-9 WeU ID# v fit 00 fit. Q�
5a.Well Location: (� loo fL
Y a "canes e 6 1 - 170 It I t - --,-
Facility/Owner Name Facility 1D# ifa pliable M ft ` r
tY (_ P ) l/� ua5 r le K'
(e ew s �.' 7ac Telyi M j)C a781[ fit ft I n. ;`G J
Physical Address,City,and bp ft ft
�CLGWP.I[ 2LREM41M
county Panel Idcrotifcation,No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field,one lat/long is sufficient) 22.Certifiicnc}ation,:n-
uod ar t[. ' rl _ 79,6 ow fig.l° `'`r rcwC� J�UIi 3 I a3
6.Is(are)the wells)i_ Permanent or OTemporary Signature ofCerntied Well Contractor Date
By signing this form.I hereby certify that the well(s)was(ivere)constructed in accordance
7.IS this a repair to an existing well: 0Yes orWN, with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Weil Construction.Standards and that a
Ifthis is a repair,fill out Imown well construction inforimation and er lain the nature afthe copy ofthis record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200"and 2QI00) construction to the following:
10.Static water level below top of casing:_ `i Q (ft) Division of Water Resources,Information.Processing Unit,
Ifu'ater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:_ 0 (in) 24b.For Infection Wens: In addition to sending the form to the address in 24a
12.Well construction method- A;f above,also submit one copy of this form within 30 days of completion of well .
y
(ie.auger,rotary,cable,direct push,etc.) construction to the following-
FORQ ,
Division of Water Resources,Underground Injection Control Program,
WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: Ca.dl-} Me 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: 1 lTH 700/O Amount:_ 1(ooL completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2 22-2016
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