GW1--05215_Well Construction - GW1_20230818

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WELL CONSTRUCTION RECORD(GW-1) Print Form
For Internal Use Only: I__ ---'--
1.Well Contractor Information:
David Belcher
14.WATER ZONES 1
Well Contractor Name FROM TO DESCRIPTION
4594-A 490 ft. 1491 ft. J(Y'P,1(&))}tare)
NC Well Contractor Certification Number ft. ft
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ep licable)
FROM TO DIAMETER THICKNESS MATERIAL/
Company Name 6 ft I 6//i , ft. 11).05 in, I SDRal PVC
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:(15(,t.)t'- tigq-n7 3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e..UIC,Comry,State,Variance,etc.) ft. ft In.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�I . icipal/Public ft, ft. in.
Geothermal(Heating/Cooling Supply) ,Residential Water Supply(single)
ft ft in.
Industrial/Commercial QResidential Water Supply(shared)
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
son-Water Supply Well: ft. ft
o
Monitoring [Recovery b ft. �� ft
Injection Well: 0�t �nc[r Chi�Os 4HrtrFe
Aquifer Recharge Groundwater Remediation R it
Aquifer Storage and Recovery ( Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QIStortnwaterDraainage ft 1it
Experimental Technology IOSubsidence Control ft R.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soillreck type,Brain size etc.)
aft. croft ;:lcif
4.Date Well(s)Completed: '731•a 3 Well ID# a0ft. 30ft fit ( I5a.Well Location: O ft. coil ft ((f l-e 1
Clarence S 1ecY) Ur 6(i ft. 5Q5 f t. ( lt,l!! '&an;++ I4 _
l���'b
Facility/Owner Name Facility ID#(if applicable) ft. ft. I C f , '
ft. ft ;
I(OGI 1e)hc ' Tr�xnn fir), l�klxb0c0/ AJcr975�1 - lull
Physical Address,City,and Zip ft ft
n� 2023
+P('SOn I g 21.REMARKS ti iOrl^nsf_I},`
County PazeelIdentification No.(PIN) DWor` e �,4,
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certif'tcati a:
?lo'8l' 14.5" N 79° I' 111.6" �►' r.�exl/�p,1�� )p
6.Is(are)the well(s)Permanent or [jTemporary Signature of Certified Well Contractor Date 31-GYJ
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: DYes or No with ISA NCAC 02C.0f00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repot),fill out known well construction Information and explain the nature of the copy ofthis 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:
YouY 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: (ft.) 24a.For All Wells: Submit this form within 30 da
For multiple wells list all depths ifd(erent(example-3(200'and 2@l00) ys of completion of well
construction to the following:
10.Static water level below top of casing:
Ifwater level is above casing,use"+ 40 (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (9 (hi.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: /Ac 4ctc' ' A;f 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:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) I Method of test:Cat-Ch'1-Tale 24e.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: IaTN 90 % Amount: I(OaL completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quali
ty ty-Division of Water Resources Revised 2-22-2016
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