GW1--04682_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD(GW 1 Print Form
Z For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A Itl a ft' 1w1 ft Q5 C.PM (' cu r-I-uksel
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-used.wells)OR LINER(If ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL -
Company Name 0 • 55 f. &.96 in. �,M, l I T vc
16.INNER CASING OR TUBING(geothermal closed-loop)'
2.Well Construction Permit#: El-LLJ'Q073O1-006 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Connor,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
AgriQuitural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL •
cipal/Public ft. ft in. _
Geothermal(Heating/Cooling Supply) "dential Water Supply(single) ft. R in.
Industrial/Commercial iResidential Water Supply(shared)
I>l..GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. (�
Monitoring DRecovery ft. �� ft 1t � Qn1t ` Chips u�k(iP.
Injection Well:
ft. ftAquifer Recharge DGmundwater Remediation
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(if applicable)
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DIStormwater Drainage ft ft
Experimental Technology IQSubsidence Control ft. ft.
Geothermal(Closed Loop) EtTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rtOther(explain under#21 Remarks) FROM ft. TO DESCRIPTION(color,hardness.soiWrecktype,grain size,etc.)
0 02O ft. (•1a
4.Date Well(s)Completed: '7-I l-g3 Well ID# do ft. 50 ft (it)t Sam Sr);1
5a.Well Location: 50 ft 5'5 ft cue (loin
Odem.octr) 65 nes erc E,c)Pn 5" it. I Ff5 ft. `blue ( Pan-e ; a 11
Facility/Owner Name Facility ID#(if applicable) It, ft. ® o.r 6.....
56l') C-c(SnSe fPntv) ?,(-)/ I�(t�r4'nl AK a?h�i�?Cj, it. ft. JUL 2, 1 202..
Physical Address,City,and Zip ft. ft.
r;::
21.REMARKS iriii3in�..!.:T. :-..e,i.":1 Un1
tnr1i;n/ham S03000�9c1Cd63D- ci:.3oG
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
36° SI' QN.7rn N 179° 3g' 1(0.r w
6.Is(are)the well(s)'ermanent or DTemporary Signature of Certified We Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or No with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of die copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back 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
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: WAS (It) 24a.For All Wells: Submit this form within 30 days of'completion of well
For multiple wells list all depths ifdiifferent(example-3@200'and 2Q100) construction to the following:
10.Static water level below top of casing: UO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use`+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter: 6 - (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Ql(� ryi(� above,also submit one copy of this form within 30 days of completion of well.
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 95 Method of test: G rr{Ch+Tine 24c.For Water Supply&infection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �rtW /� �p Amount: I(noz completion of well construction to the bounty health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016