GW1--05865_Well Construction - GW1_20230912

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V�IELL coNs'A'It1tTr�rtrnR�RECORD
Prlrtt Form
V1` (GW 11 For Internal Use Only. •
1.Well Contractor Information:
David Belcher
14.WATER ZONES I 1
Well Contractor Nama I 1
FROM To DESCRIPTION
4594-A 150 ft' 15?, ft. in cif' A' (Cca cArAcp)
NC Well Contractor Certification Number ft' ft.
Aqua Drill,Inc. IS.OUTER CASING(for muh.cased wells)OR LINER(If VP cable)
FROM I TO{ DIAMETERTBICKNESS MATERIAL
Company Name O ft. l jC) I ca.of 5 Ia 11DR al 'PVC
2.Well Construction Permit#• el 16.INNER CASING OR TUBING(geothermal closed loop) .
List all applicable well construction permus,�e.UIC,County,State,'Variance,etc FROMft. TO DIAMETER THICKNESS MATERIAL
� � lo.
3.Well Use(check well use): ft. ft in.
Water Supply Well: 17.SCREEN
Agricultural ,• FROM TO DIAMETER SLOTS= THICKNESS MATERIAL
ill Geothermal 0 oipal/Public ff. ft. in.1
(fleating/Cooling Supply) �l1I1 Residential Water Supply(single)
ill'Industrial/Commercial °Residential Water Supply(shared) it. R• in.
1S.GROUT
W.hri:ation
Non-Water Supply Well; FROM To MATERIAL EMPLACEMENT METHOD&AMOUNT
N on-Water
0 D' �11
Recovery fcnEarli k� �1at( Ch��g uar�rFe
Injection Well: — ft. R. 0
*Aquifer Recharge I°GroundwaterRemediation ft• ft.
ail Aquifer Storage and Recovery °Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
illAquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
°StormwaterDrainage ft. ft.
ill Experimental Technology °Subsidence Control
lit Geothermal(Closed Loop) DTracer
20.DRILLING LOG(attach additional sheets if necessary)'
(Geothermal satin,Coolim_Return) 11iOther(e .lain under#21Remarks FROM TO DESCRIPTION(color.
) 66rdaese,wlUreca type,crabs size,etc.)
4.Date Wells)Completed: $1 ' Well ID# 0 ft. 00 ft Clct ;
So.Well Location: g0
O
ft' ong' Sr<l�(
saf�ll 1-lncr►5 8oe�j f. ft
' ( Se);(
Facihabell It rc5 ft• iia f. It°-&'i 'ke
Facility ID#(if applicable) R is
�l� ao75 lue C-cyan;•l•P
L115 Kcnn(<t IA, ie.d svlllP, AIr g7:1490 ft. ft. (.:v `._ --•r.^. kr,-..
Physical Address,City,and Zip ft. fft. , � el,...,:,tq i+• ,
89V 00,265706 21.REMARKS
County .
! f N a :' 1023
Parcel Identification No.(PIN) ,I
Sb.Latitude and longitude in degrees/minttteslsecDnds or decimal degrees: I n,`;,rir zs�n .;�,*,1 il�L.f,jt
(if well field,one Iatilong is sufficient) �°• "•':,,J J
22.Certification: i,
6.Is(are)the wells) erman t or ®(Temporary Signature set Well Contractor R-5.23
7,Is this a repair to an existing well: Yes or 1`rO ate
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
' with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constrac ion Standards and that a
If this Is a repair,jill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or an the back of this form.
23.
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You
diagram
use the back of this al well details:
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells You may page to provide additionalnpages well site detailsy or well
drilled:
construction details. You may also attach additional if necessary.
SUBMITTAL INSTRUCTIONS !
9.Total well depth below land surface: ,2,95
For multiple wells list all depths lfd8erent(example-3@200'and 2(0100� (B') 24a.For MI Wells: Submit this forDt within 30 days of completion of well
construction to the following: 1
10.Static water level below top of casing: Lin (ft.) Division of Water Resources`Information Processing Unit,
If water level is above casing,use"+'
•
1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: Cg (In.) 24b.For Infection Wells: In addition io sending the form to the address in 24a
12.Well construction method: ?tOirl A'( above,also submit one copy of this farm 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 Centei,Raleigh,NC 27699-1636
13a.Yield(gpm) 16 Method of test: CAA Iv, 24c.For Water Snooty do Infection Wells: In addition to sending the form to
e• the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection
typ • I1 T� '70% Amount: `(ee2 completion of well construction to the col my health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
1 Revised 2-22-2016