_Well Construction - GW1_20230327 (42)

Q'r�1 For Internal Use Only - -.. ... `
1.Well Contractor Information:
David Belcher
Well Contractor Name 14•WATER ZONES TO
FROM
4594-A DESCRIPTION
r ft
NC Well Contractor Certification Number 0 It v.ft ft. 1
Aqua Drill, Inc. 15.OUTER CASING for multi-eased wells OR LINER rfa licable
FROM TO DIAMETER THICKNESS
Company Name ft. MATERIAL
O ft. in. cr
2.Well Construction Permit#: 16.INNER `s• 1
List all applicable well construction permit �n�O�n Stat©Y ante,etc) CASING OR TUBING eothermal closed-!oo,
FROM TO DIAMETER
it. © � MATERIAL
3.Well Use(check well use): in.
Water Supply D' ft in. _
Pp y Well:
17.SCREEN
Agricultural QI)k'rmicipal/public mons TO DIAMETER SLOT THICKNESS sE:P ft. - in. __
*GeothermalMATERIAL Supply) Residential Water Supply(single)
®�lndustriaUCommercral OResidential Water Supplyhft. in. _—
(shared)
Irti:•lion18.GROUT
Non-Water Supply Well: FROM TO
Q ft EMPLACEMENT METHOD&AMOUNT
*Monitoring ft
Injection Well: Recovery a,�= • -11
MEI
!Aquifer Recharge °Groundwater Remediation ft.
*Aquifer Storage and Recovery S 19.SAND/GRAVEL PACK if A,,livable
alinity Barrier FROM TO
*Aquifer Test Stomrwater Drainage ft.
MATERIAL EMPLACEMENT METHOD
*Experimental Technology
Subsidence Control ft. IIIKIIIIIIIIIIIIII
211 Geothermal(Closed Loop)
Tracer 20.DRILLING LOG attach additional sheets if necessa
Geothermal(Heating/Cooling Return
Other(explain under#21 Remarks) FROM TO DE CR PTIoN color, ,
mt
hardness,soil/rock
. ftt.e._ etel
4.Date Well(s)Completed: - Well ID# •
�q it '
5a.Well Location: ' • ft
e.ey r
r+ ug ft 53 ft V "- a
Facility/pwnerName ft.
Facility ID#(if applicable) It MI
1622_6.11 �R� t
Physical Address,City,and Zipft' {;4, U 1
, f. g• i za :l..
[:llt�l a�9 I c2J� 21.REMARKS A' 9 �•
County t.
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: Ifr;C• " r `'`„' *_.
(if well fief one la `-'.",
d, Ulong is sufficient)
J LyV
° 151 G� Q" iy ' l� 4,, 22.Certification:
W
6.Is(are)the well(s) _ Permanent n or Temporary Signature of Certified Well Contractor -��-a
7.Is this a repairDate
to an existing well: Dyes or ivp BY signing this form.I hereby certify that the well(s)was(were)constructed in accordance
with If this is a repair,fill out!mown well consrrction information and explain the nature ojthe 154rNCAC O has be0e0»o ay d dro the wet.)200er.ell Construction Standards and that a
repair under#2I remarks section or on the back of this form. of
8.For Geoprobe/DPT or Closed-Lou Geothermal Wells havingthe same 23.Site diagram or additional well details:
construction,only 1 GW-1 is needed. Indicate TOTAL You may use the back of this page to provide additional well site details or well
drilled: NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface:_ TT�INSTRUCTIONS
For multiple wells list belll ow
depths different(example 3@20o and2@10o� (ff) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing: ConStIuetion to the following:
(ft.) Division of Water Resources,Information Processing Unit;
If cater level is above casing;use"+"
11.Borehole diameter 1617 Mail Ser�Rce Center,Raleigh,NC 27699-1617
12.Well construction method: 24b.For Iniection Wells: In addition to sending the form to the ad
'r ess in 24a
above,also submit one copy of this form within 30 days of completion of well
(ie.auger,rotary,cable,direct push,etc.) ' construction to the following:
FOR WATER SUPPLY WELLS ONLY:
Division of Water Resources,Underground Injection Control Program,
13a.Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: {Ch�Y p 24c.ForWaterS l
13b.Disinfection '�J..( `J D &In ection Wells: In addition to sending the form to
type: Q O the address(es) above, also!submit one copy of this form within 30 days of
Amount:_ ��Qn7 completion of well construction to the county health department of the county
Form GW_1
North Carolina Department ofEnvironmenta!Quality-Division of Water Resources
Revised 2-22_2016
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