GW1--06051_Well Construction - GW1_20230920

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WELL CONSTRUCTION RECORD(GW-11
For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A 14110 ft Lit-11 ft' rq OA 0-carku.-
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-eared wells)OR LINER(If an licable)
Aqua Drill,Inc. FROM TO DIAMETER ' THICKNESS MATERIAL
Company Name 6 f6 (1 ft G. n •17. Oat I QVC
16.INNER CASING OR TUBING n(geothermal closed-loop)
2.Well Construction Permit#: Ar/�)9p FROM TO DIAMETER .' THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County,State,Variance,eta) ft' R. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
(micipal/Publio ft. ft. in. '
Geothermal(Heating/Cooling Supply) IffResidential Water Supply(single) ft, ft, in.
Industrial/Commercial °Residential Water Supply(shared)
is.GROUT
Irrigation FROM TO MATERIAL , EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft.
t /�
Monitoring Recovery Q ft. ft.f 11°(5tnfli�t? Y(�(RC (1'11 4- -}aaS {P.
Injection Well: '
ft. ft.Aquifer Reeherga °Groundwater Remediation Aquifer Storage and RecoverySel' ' Barrier 19.SAND/GRAVEL PACK(if applicable)
inityFROM TO MATERIAL ' - EMPLACEMENT METHOD
Aquifer Test °Stonnwater Drainage ft. ft-
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRiLLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) ER" TO DESCRIPTION(color,hardness eoIDmcktype, sin size etc.)
6 ft. ,v .)ft. CIC
4.Date Well(s)Completed: 9'/W-e93 Well ID# ft. 562 ft. �f 5 Sri;1
Se.Well Location: 5(p f` 64 ft: 311 e r-fra ate
I'M,. rlatYs Cl ft. Ulo5 ft' Jae (4ra(If4
Facility/Owner Name Facility lob(if applicable) ft. ft. ,
1uc17 05.157, ' ep utltpl Nc I9V ft. ft. s' •r ^ da L`
Physical Address,City,and Zip ft. ft. 4 6"�^ °^�" ''
Cris( ee It 21.REMARKS ��p O ?O��
County Parcel Identification No.(PIN) I
Sb.Latitude and longitude indegrees/minutes/seconds or decimal degrees: 1nf Or r•-:".3 i'{•-r :. :;y
(if well field,one fat/long is sufficient) tit+ ^jam
M.Certification:
3C 4. 1l' pia.3" N y9°.2,9' 3►_9" W ► n,0` ,o 9.&o.r�3
6.Is(are)the wells) ermanent or °Temporary Signature of Certified
Weil Contractor Date
RBy 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Phis is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 021 remarks section or an the back ofthis form.
23.Site diagram or additional well details:
8.For Ceoprobe/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 i 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: tiro (ft-) 24e.For All Wells: Submit this form within 30 days of completion of well
For multiple welts list all depths(fd fferent(example-3@200'and 2@100')
construction to the following:
10.Static water level below top of casing: yQ (ft.) Division of Water Resources,Information ProcessingUnit,If water level is above casing,use"+' t,
1617 Mail Service Center,Raleigh,NC 37699-1617
11.Borehole diameter: CP (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: f�ylG+ryy� a` above,also submit one copy of this form within 30 days of completion of well*
(i.e.auger,rotary,cable,direct push,etc.) it ` construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) o� Method of test: r" 4 Tint? 24c.For Water Supply&Iniectionl 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: 1-4 1-1 (r)(9/p Amount: 1(of7. completion of well construction to the county health department of the county
where constructed. I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016