_Well Construction - GW1_20230327 (61)

WELL CQ ST..IJJ :'1 0N-RECORD LW-1
For Internal Use Only:
1.Well Contractor Information:
David Belcher
Well Contractor Name
14.WATER ZONES
FROM TO DESCRIPTION
S O ft
4594-A
9. • dipA n,lilt.L)
•
NC Well Contractor Certification Number ft. ft
Aqua Drill, Inc. 1S.OUTER CASING for multi-cased wells OR LINER if a, licable
FROM TO DIAMETER THICKNESS
Company Name Q ft I MATERIAL
2.Well Construction Permit# 16.INNER CASING OR TUBING •eothermal closed-too` Y u C
List all applicable well construction permitsU C,Cf unOOfate,Parlance,etc.) FROM
TO THICKNESSDIAMETER MATERIAL
3.Well Use(check well use): ft. in.
•
ft in. —
Water Supply Well:
�T 17.SCREEN
Agriculturalf�liunicipal/Public FROM TO DIAMETER SLOT SIZE
p ft. TTiICIQNFSg MATERIAL
NI:*Geothermal(Heating/Cooling Supply) Residential Water Supply(single) °• in.
®'Industrial/Commerciale pP y( BeR.d
Residential Water Supplyin.
*Irti•.lion (shared) 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
( ii
*Monitoring ft t
Injection Well: Recovery .9ft C
*Aquifer Recharge Groundwater Remediation ft
L.;,.1
Aquifer Storage and Recovery 0Salinity Barrier 19.SAND/GRAVEL,PACK if livable
Aquifer Test �-�
0 FROM TO MATERIAL EMPLACEMENT METHOD
SWrmwaterDrainage ft ft
*Experimental Technology �OSubsidence Control
Me Geothermal(Closed Loop) OTracer
•
*Geothermal
othermal 20.DRILLING LOG(attach additional sheets ifnecessa
(Heating/Cooling Return ill'Other(explain under#21 Remarks FROM TO DESCRIPTION hardness so Wrack
ft e, n etc
4.Date Well(s)Completed: -l L(-
Well DM O 5(0
5a.Well Location:
5 ft. ft
AOIePica S iol j l i it_
—'_-�— Qf� Tnr -SILL_ — ��1 C CC
Facility/Owner Name `'a`�' O L4
�/��/ FaciItylpll(if applicab1e) ft ft
Physical Ip I C10 l ft � .s" ,i,i'`I�_
Address,r,lty,and Zip
ft ft M i ft
[ .,
County
Ln0 cf21662 gQ 21.REMARKS
Parcel Identification No.(PIN) ;'"
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: r t `~I! .)i.z
(if well field,one let/long is sufficient)
30 [x t!t` e , ,r 22.Certification:
(
Nam_ 31 11 (o 1p
(DaveS 6.Is(are)the wells) er nent or Tem or — - `p
P ary Signature of Certified Well Contractor
Date
7.Is this a repair to an existing well: �ycs Or NoBy signing this form,I hereby certify that the well(s)was(were)constructed hi accordance
Ifthis is a repair,fill out known well construction irrjormation and explain the nature of the
copy of this record has been provided to the well owner.
with I56 NC,1C 01C.0100 or 154 NC4C 02C.0200 Well Construction Standards and that a
repair under#21 remarks section or on the back-of this form.
23.Site
8.For Geoprobe./DPT or Closed-Loop Geothermal Wells having the same You ma diagram or the back ofhthis well details:
construction,only I GW 1 is needed indicate TOTAL NUMBER of wells ,page to provide additional well site details or well
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: �� SUBMITTAL INSTRUCTIONS
For multiple well
wells si all depths ndiffer surface:
(example-3(a 200'and (ft) 24a. For All Wells: Submit'this form within 30 days of completion of well
10.Static water level below top of casing: JCO construction to the following:
If water level is above casing,use"+" (ft.)
Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
12.Well construction method: 24b.For In ectioa Wlic: In addition to sending
��aF r� '1+ above,also submit one copyt the form to the address in welll
(i e.auger,rotary,cable,direct push,etc.)
above,construction to the following: of this form within 30 days of completion of
•Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)_a 1636 Mail Service Center,Raleigh,NC 27699-1636
---__Method of test:COkh1 `j ryrp 24c.For Water Supply&Injection Wells In addition to sending the form to
13b.Disinfection type: tf��� the address(es) above, also submit one co of this form
Amount: EoA completion of well construction to the canny health within30 daysof
where constructed, ty department of the county
Form OW-1"
North Carolina Department ofEnvironmental Quality-Division of Water Resources
Revised 2-I2_2016