GW1--03605_Well Construction - GW1_20230522

WEL 1,Co [S JC N RE 7ORD GW-1 ..
For Internal Use Only: ---- - .�---
1.Well Contractor Information:
David Belcher ! I
! I
Well Contractor Name 14.WATER 7.oNES I I
FROM TO DES IIPT[ON
4594-A n O f` 7
NC Well Contractor Certification Number of -5 f` 9,90'L (,
Aqua Drill, Inc. IS.OUTER CASING for multi-cased wells ORLINER Us licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL NO a 5 to S a 2.Well Construction Permit#: ,
�/Gc, 16.INNER CASING OR TUBING eothermal closed V
'S(.n'-)7S FROM To
List all applicable well construction permeis(,.e ULC,County,State,Yarianoe etc.) ft. DIAMETER.
THICHGNE8S MATERIAL
3.Well Use(check well use): ft. ft. in
Water Supply Weli: 17.SCREEN
Agricultural unicipal/Public FROM TO DIAMETER SLOTSI7.E THICKNESS MATERIAL
Geothermal � fr 1°(Heating/Cooliag Supply) Residential Water Supply(single)
IndnstriaUCammercial it ft in.
OResidential Water Supply(shared)
H ation 18.GROUT
Non-Water SUpgly Well: FROM To hIATERrAL ER7pLACEh7ENT METHOD&AMOUNT
n ft
Monitoring, Recovery 'E'
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation ft.
D'
Aquifer Storage and Recovery loSalinity Baaier 19.SAND/GRAVEL PACK rF ]-cable
Aquifer Test mOM TO •hTAT�At EiVIPLACEh1ENTMETHOD
OStormwaterDrainage ft, ft
Experimental Technology oSubsidence Control
ft. ft.
Geothermal(Closed Loop) OTracer
20.DRILLING LOG attach additional sheets if Aires Geothermal(Heating/Cooling Return) rl"er(explain under#21 Remarks) knoll To DFscRlerloN solar,hardn
Oft. 20 ft: ess,soiltrock typc, "s etc.
4.Date Wells)Completed: -) -a Qy ID# ft.
5a.Well Location: ft. I % r
1 5 f`
r
Facthty/Owner�Name ft`. Facility ID#(if applicable).�� ft OX ft, I; r
ft. ft.Vhy,ua,Address,city,{and Zip
IL
21.REMARKS H
County Parcel Identification No.(PIN) r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:(ifwell field,one lat(long is sufficient)
�/ r� 22.Certification:�SC2 =2_1 14U Qrf N O r
6. S(are)thewell(s) rmauent or [ITemporary SrgnatureofCcmtledWllContractor I&O.
Date
7.Is this a repair to an existing well• Tres or No wi signing this f0rm,I hereby certify that the wells)way(were)constructed in accordance
Iftrep it is a repair,re out known wet!construction information and explain the nature ofthe Y fthis record has been prolided to be�1l owner.e11 Construction Standards and that a
repair under#21 remarkr section or on the back ofthisform.
23.Site diagram or additional WeR 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
drilled:
Pages if necessary.
9.Total well depth below land surface: _ SUBM[TTAL INSTRUCTIONS
For nrtrltlple wells list all depths 0iQereat(example-3@200'and 2Q100�—(R�) 74a• For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: LI0 construction to the following:
Ifivater level is above casing;use•'+" ( ) Division of Water Resources,Information Processing Unit,
Il.Borehole diameter: (in.)
1617 Mail Service Center,Raleigh,NC 276994617
_ �n
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: r above,also submit one copy of this fora within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following-
FOR
WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Prograln,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)_I�p Method of test: ��kCh �l-Y'MP 24c.For Water SHEMI &Injection Wells: In addition to sending the forth to
one copy of this fo
13b.Disinfection type: HIH Odl ICoOZ comaddress(es)
dress of well oconstrucflon tove, also tthe county health pm within the county
O Amount
where constructed.
Form GW-1 North Carolina Department of Environmental
Quality-Division of Water Resources Revised 2 22-2016
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