GW1--04886_Well Construction - GW1_20240828

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only'
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Wet Contractor Name FROM TO DESCRIPTION
4594-A ?e 4 et. 99 ft' s c.o vitt irt.s.e)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. Lis ft. c',S in. sDR 9 t 1 p Vt c
16.INNER CASING OR TUBING(s.eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.U/C,County.State, Variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. R. in.
Water Supply Well: 17.SCREEN _
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ED unicipaUPublic ft ft. in.
QGeothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. R. in.
JIndustrial/Commercial OResidential Water Supply(shared) -
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: V i+t fL 070 fL (hp �`
°Monitoring Rccov i'1l �eti+@ Pair (hp I (3;
ary ft. ft.
Injection Well:
A uifer Recharge ft. ft.
q arg Groundwater Remediation
Aquifer Storage and Recovery D SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test fStormwater Drainage ft. ft.
QExperimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) ID Tracer 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/� �f�r ft. ft. e_
4.Date Well(s)Completed: q'Of 1,7'i Well IINt 00, ft. n ft. �f�Ci19 Sotsel, ci p
Sa.Well Location: yb ft. 45, ft. $1 C�'(1e {w
ft. 3. I ft. Sid?, C•cctn., e a,..
Facility/Owner Name Facility iD#(if applicable) ft. ft. _ Al(i.1 L S 2'124
073iel lti ,05 Rt3i A@elel)et hit a70,95 ft. ft.
Physical Address,t fey,and Zip ft. ft.
5 o Ilc 21.REMARKS -
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.Certifies'on
3(ao , y Sid N We qi LI C W ` ai
Signature of Certified ell Contractor e
6.ls(are)the well(s) Permanent or Temporary P 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: QYes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction 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 the well owner
repair under#21 remarks section or on the back of this form
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:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3,25 (ft•) 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@a 200'and 2 a@lO(y)
construction to the following:
10.Static water level below top of casing: 40 (ft.) Division of Water Resources,information Processing Unit,
If rioter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
h above,also submit one copy of tt.is form within 30 days of completion of well
12.Well construction method: grejt,(�t�' A-,, construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: &d-c l+Told 24c. For Water Supply&Iniection Wells: In addition to sending the form to
L�
C the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HMI?o 4o Amount: I(&. completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources p,..,,s,.n s-n in 1 e