GW1--05933_Well Construction - GW1_20241009

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A 370 ft, ri f. 6(pt{ ( ""ae+ure)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
/�yy it. ft. in. o
Company Name 0 /10 G 45 R/V I v t. -
'f �p 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: {), Gfl(�`�71'( FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UiC,County,.State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. It, in.
Water Supply Well: 17.SCREEN.
�{ FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural • C� nicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) jFr;Residential Water Supply(single) ft. ft. in.
Industrial/Commercial EDItesidential Water Supply(shared) la.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 191 ft. na i1ii°rlf ()ITS *l'aCf fz
Monitoring fRccovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EDSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test EDStormwater Drainage ft. ft.
Experimental Technology 0 Subsidence Control ft. ft. ,
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) _ .
Geothermal(Heating/Cooling Return) FROM TO DESCRIPTION(color,hardness soil/rock type.grain size.etc.)
g/ bf(�Other(explain under#2I Remarks) o It
ft.
f t�
20
•
4.Date Well(s)Completed: IC)"i• L1 Well ID# �r)tt- j ft- •�f-'�.'nr) Soli
5a.Well Location: co(Dft. too ft. 5O11
Ckfr)r;l l•[ ryP:s. di L3RuceSbro 1100 ft' lin ft. $iat._(an, j
tt`!ryA
Fact /Owner Name FacilitylD#(ifapplicable) ho it. ileac it. eR17te. /IronHe _ ' •4:, t. iir. : °, i-- i--1
51?.3 dUifcse &)r Anj.: , A)C c� ft. ft OCT ;3, LI 2(24
Physical Address,City,and Zip
tr 597 AO- S-ORM 21.REMARKS t
County Cr Parcel Identification No.(PIN) D b,c''1f+-P.i 1
5b.Latitude and longitude in degrees/tninuteslseconds or decimal degrees: •
•
(if wall field,one lat/long is sufficient) 1 22.Certification: I
3�°' ° t"o" N ®° 3�J® t-i`i.Str . w /1_ /��f� (`�� 0�7
6.Is(are)the well(s) Permanent or Temporary
Signature ofof Certified Well Contractor Date
By signing this form,I hereby ceriti'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: EDYes or No with!SA NCAC 02C.0100 or/SA RCAC 02C.0200 R'ell C nstrmrioa Standards and that a
If this is a repair,fill out known well construction informatioa'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 additioual well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page provide additional well site details or well ,
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. •
drilled: 4425
e. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: I . -egi5 (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: •
10.Static water level below top of casing: I 110 (ft.) Division of Water Resources,Information Processing Unit,
If s ater level is above casing,use"+" i 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
; t above,also submit one copy of this form within 30 days of completioiof well
12.Well construction method: elf't nr4
construction to the following: I
(i.e,auger,rotary,cable,direct push,etc.) �
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i ' 1636 Mail Service Center,Raleigh,NC 27699-1636
•
13a.Yield(gpm) ®Q Method of test:._CM-Ch* -gm,, 24c.For Water Supply&Injection Wells: In addition to sending the form to
617e, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: WM"76 ' Amount: /roof_ 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