GW1--06203_Well Construction - GW1_20241021

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 Cl)r ft. 19a it `- PA4 (Vene4iit-
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 THICKNESSy MATERIAL
Name • V
P? Jc�y ft. / ft. r:2J in. ivr I 'Pli .
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:E)-1E,.8'P91.1( -131.3 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnuclion permits 0.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): it. ft. in.
Water Supply Well: 17.SCREEN
AgriCllltural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
�> unicipalPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) p►jiRcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial DRcsidcntial Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. (�
MonitoringRecovery 0 ft. cog' ft. SC'1 n'F C"rf� f72. Ct f' C�'1jp�,'�'Venire
Injection Well:
Aquifer Recharge ft., ft.
1; Groundwater Remediation
Aquifer Storage and Recovery 0 SalinityBarrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Storrnwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soi
Geothermal(Heating/Coolin Return) l/roek type,grain size,etc.)
)
nOther(explain under#21 Remarks)
,►m" ft. A ft. en
4.Date Well(s)Completed: j8-tQ-c'sM',j Well ID# (90 ft. 1/6 ft. eDV a S:,/ cma
5a.Well Location: U� ft. 5'j0 ft. �1 • C«r ^?r1
i
la &ct I-ksp Rairktlilie ,0 ft' s ft. "SPl 1' iAi>..3A`e '._ -`T- ; _
Faciillitti//Owner Name ^� �q nFacillity lD#(if applicable)le)7 g ry Ea R' ,V('y�5 R' r{'llae. rscriflii f� ` ``'v.-. s'-'"
917 O ()®f`S taro idia1. ? F�ICf in, Mc ,a73, cr, ft. ft. on 2 1 i :,
Physical p1 t 1
Address,City,and Zip ft ft.
') Ir /4ryt ViSztvti7a3
21.REi1fARKS
County Parcel Identification No.(PIN) �+'�a i,c
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
eat 1a•11/. 2
6.Is(are)the well(s)'rAi Permanent or IDTemporary Signature o edified Well Contractor Date
By signing this form,I hereby cert +that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: (OYes or NO with ISA NCAC 02C.0100 or 1SA 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 al/his 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: r :c (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and12@100') construction to the following:
1
10.Static water level below top of casing: U0 (ft.) Division of Water Resources,Information Processing Unit,
!flutter 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
12.Well construction method: 'gt'Al,a:`� eC 0 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) e I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: i 1636 Mail Service Center,Raleigh,NC 27699-1636
I3a.Yield(gpm) 5 Method of test: C,( i-�'h4'rime 24e.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: 14'IH706/0 Amount: t(oee 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
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