GW1--05217_Well Construction - GW1_20230818

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
David Belcher 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
4594-A DO ft. $ya ft. (oOR (6ti(.fre)
ft. ft.
NC Well Contractor Certification Number -
15.OUTER CASING(for multi-eased wells)OR LINER(If ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. al ft. Co.CI in. gag r INC
/� /� /� 16.INNER CASING OR TUBING(geothermal closcd-loop)
2.Well Construction Permit#:()SW Y-CO03�D-ao<93 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. It. In.
Water Supply Well: V.SCREEN
FROM TO 'DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural icipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Elitesidential Water Supply(single) - ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AAMOUNT
Non-Water SupplyWell: Recovery O ft. (Q°� ft. �P(TS'0f)i•�P f c. Crt;ps 4- -1r)R t
MonitoringQ
Injection Well:
ft. ft.
Aquifer Recharge DGmundwater Remediation
19.SAND/GRAVEL PACK(If applicable)
Aquifer Storage and Recovery ElISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test oStormwater Drainage ft. ft.
Experimental Technology EDSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional Sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness solWreck type Grain size etc.)
Q ft. 10 ft. (kz'
4.Date Well(s)Completed: S.`7•r23 Well ID# /0 ft. 090 ft. (I.( Sred Spi,`
5a.Well Location: e 0 R. (D`'If ft. Ill (xfQ
Shiel As Mclflent,Jn (9u ft. 05 tr. `8Iue 9i ni4e a e'" --o t s
Facility/Owner Name Facility ID#(if applicable) R. ft. °''•. A.!L
9q („1nlnt(4 q',lp a T'm�arldie)Mc k• rt. AUG 1 R ? 1 .
Physical Address,City,and ip ft. ft. s.u 4 j
21.REMARKS I^•"•� sn r'rt+C�roi. ,. .
'prsoa A,5 3M LWIOZ0G s,�
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:
3(9° I(°' t49.8'" N V$'° 54' 34.9" w (notj i Z•to•,-7.?
6.Is(are)the well(s).Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or EKTo with 1SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,f hl out known well construction information and explain the stature of the copy of this record has been provided to the well owner
repair under#21 remarks section or on the back of this fort.
23.Site diagram or additional well details:
8.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:
CC��
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5(051 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100' construction to the following: y p
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (o (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
A above,also submit one copy of this form within 30 days of completion of well•
12.Well construction method: ac/ Nit construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) d' ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) CO Method of test: C.4Ch 4`lltte 24c.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
13b.Disinfection type: 1-1YIk V( v/ct Amount: I(DOZ 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 Revised 2-22-2016