GW1--06404_Well Construction - GW1_20241025

•
•
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES - i
WeIlContracrorNama FROM TO - DESCRIPTION
4594-A j4gf(' t1•�i,11 ft. 2o1r4 'N-teitnyl
ft. ft.
NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells)OR LINER(if ap [feeble)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name ® ft. 5A ft. 6,95 in. ,50191
5 rl t Vii
�+t,,��yyee11 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:�j.2pt✓'.9x-c26.14 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. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0/unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Et'Residential Water Supply(single) ft. ft. in.
industriaUCommereial DResidcntial Water Supply(shared) 18.GROUT -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. ft. rttlri(j(Pr� 9-4,Ic yvga ti-14;�o(t.
Monitoring 0Recovery ft. ft. u //
Injection Well:
_ ft. ft.
Aquifer Recharge 0 Groundwater Remediation ,
19.SAND/GRAVEL PACK(if applicable).
I Aquifer Storage and Recovery 0ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional,sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soiUrock type,grain size•etc.)
t Geothemlal(Heating/Cooling Return) 1i' Other(explain under#21 Remarks) •
,
0 ft. 120 ft. CIO
4.Date Well(s)Completed: lb.. l•4441 Well ID# ft• 50 ft. /Dr Ile ,Ij1
5a.Well Locations. SO ft. Kg; ft. C. lla(`life.
1.00 Tet"n 'PTCI r{eve e_44 Ic- ft. gas ft. Ak.te 'C`ft'3.7ti, i`:,. .m L 3.
Facility/Owner Name 9 Facility iD#(if applicable) ft. ft.
wag gdimo9 kW;Emil'PyPiplie.VC 9W:71g
Physical Address,City,and Zi ft. ft. .r- e• ,,, F:_J t�,,�T,.
Rt� l«°! 21.REMARKS t(ho.•-,:-..:Y r
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/long is sufficient) g 22.Certification:
6.Is(are)the well(s) ermanent orTemporary Sig to of Certified well Contractor Date
By signing this firm.I hereby certify that the well(s)wax(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or No with ISA NCAC 02C.0100 or ISA NCAC 02C.0200{Veil Constru,ctio,Standards and that a
!Phis is a repair,fill out known well construction information and evplaln the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks section or on the back ojthis 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: "J(I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list al/depths ifdi/jereat(example-3 a 200'and 2 a 100') construction to the following: '
10.Static water level below top of casing: go (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: 0 (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
I pt above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1'r t, t /i,r 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) a Method of test: t 4-7?tne 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: MTV NiQ /f) Amount: /020Y.. completion of well construction ti 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