GW1--04556_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
David Belcher 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
4594-A ;10 tt. i ft. ,16 ay
M
rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased well9_,OR LINER(if ap Usable)
Aqua Drill, Inc. FROM TO DIA)IETEP__ THICKNESS MATERIAL
Company Name V ft. '� ft. CO• 5 in. I y,Y).1 ,/1.,``
-
16.INNERCASINGORTUBING(geothermalcllosseld--looAp) 1 V4
2.Well Construction Permit#: E I-14)P tllo41-00V FROM TO DIAMETER THICKNESS MATERIAL
—
List all applicable sell construction permits(i.e. ((IC,County.State, Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well: 17.SCREEN _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ® unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) gResidential Watcr Supply(single) ft ft. in
IndustrialiCommercial DResidential Water Supply(shared) IS.GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. at n. (,j._or��ve F.C{i-{� CL�(�5 �' i'ip wit
Monitoring 0 Recovery ft. ft Trail l�l ` t
Injection Well: it. it.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL,-1 EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage
it. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothemtal(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.soil/rock type grain size.etc.)
,,�� 0 ft. 20 ft. on
4.Date Well(s)Completed: 7 Z0'of"il Well ID# do ft. �5 ft. Te.�S ft. go n. cir�(�(� 50,1
Sa.Well Location: �' �.�
ft. ft.
f Art itky If }rm !-motes p�'r tort r ' froJ SIP (� itilE
Facility/Owner Name Facility ID#(if applicable) ft. ft.
► nnu 'Rc)1 lajoNit.t:aI4h king9375 ft. it.
Physical Address,City,and Zip ft. ft.
21.REMARKS
' ►�. 1•idin 7)Cs 7 (2®iq ill` 3 1 ?P i
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: It`;:-.
(if well field.one
`,late '�Q
Iong is sufficient) 't 22.Certification:
7 c 25• a.,/' N 4 tl 4 ' id.r w e ,
7 a?2•.2y
6.Is(are)the well(s) Permanent or f Temporary Signature o Certified Well Contractor Date
Br signing this form,l hereby certi/v that the wells)uses(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C.0100 or 15A NCAC 02.0.0200 Well Cmutruction Standards and that a
if this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to toe well owner
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3i15 (0t) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(cu200'and 2(t4100') construction to the following:
10.Static water level below top of casing: 50 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: co (in.) 24b. For Injection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
•12.Well construction method: pint Alf construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) C/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) It Method of test: CCA'61 4-1t1 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: 14114 706/e3 Amount: KO CZ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-21)16