GW1--05934_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 pq�
4594-A p�B© ft. alb ft. 5,0 r, CD•t cittre)
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
6 ft. 0 ft. 6.r in. 5 fla 01 PVC
Company Name • _16.INNER CASING OR TUBING(geothermal closed-loop).
2.Well Construction Permit#: 4f FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(.e.UIC.County.State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. R in.
Water Supply Well: 19.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ® unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) f'R
esidcntial Water Supply(single) ft. R. in.
Industrial/Commercial (Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . ft.
ft I n '
0 nag '1t e Aie tkr tys A-yolee..
Monitoring DRecovery ft. ft.
Injection Well:
ft ft
Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if nere'eeary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(mar,tanm�wi!/roctc type Aram si ete.)
�g d ft Ot� ft r.ki :: c
4.Date Well(s)Completed: aR°of °9U Well BM t ft. ed ft T ,Cj, -I,- CtDig '\.- '' a•..: 'i 7._.t„'''
5a.Well Location: 46 ft. se it I(! -t
ldYp�,1 OCT e Ia t 2024
'l,t'0:A (f, cireenocorl 5a f'• d'06 f' 'kw. '(3f f4Ore
Facility/Owner Name Facility ID#(if applicable) ft. ft. Ir.sc,:.R-.i''-:". '-r's0,4:-, !;F;k
ft. ft. U ...e.:: 3
110114(12I25K, .5 'Re)) 4fosn tai>4tn . .J� g7of9.
Physical Address,City,and ZipSio
/ R• R•
r,�� 21.REMARKS -
County �l Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Jar/long is sufficient) ' 22.Certification:
' t9' 4.gr° N i'O`' 6' 51°Jet w jil r
11/` it, 3•,9
11
6.Is(are)the well(s)iL iPermanent or EITemporary Signatii ofCcrttficc�Well Contractor Date
_ B signing this form,I herebycertr wel
l(s)the el!s was were constructed in accordance
7.Is this a repair to an existing well: IDYes ord 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: 4.5 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200' Qaand 2 100') construction to the following:
10.Static water level below top of casing: 126
(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 Infection 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
�j
12.Well construction method: t ator 1(1 kr construction to the following: '
(i.e.auger,rotary,cable,direct push,etc.) �-
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 59 Method of test:_(,k h+rine, 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: k174'70°41 Amount: Lip;, completion of well construction to the county health department of the county
where constructed.
1
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016