GW1-2023-02799_Well Construction - GW1_20230417

WELL CONSTRUCTION RECORD G'®V 1
For Internal Use Only:
1.Well Contractor Information:
David Belcher
Well Contractor Name 14.WATER ZONES
FROM ' TO DESCRIPTION
4594-A () 0 rt An (A VA T iT)
NC Well Contractor Certification Number ft
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)ORLINER(if ap licable) '
FROM I TO ! DIAMETER ! THICKNESS MATERIAL
Company Name b ft P5 ft I 6.026 ' I ,lfRc21 PUG
2.Well Construction Permit ft: p( r� �� 16.INNER CASING OR TUBING(geothermal dosed-loop)
List all p (. ry, FROM TO DIAMETER THICKNESS MATERIAL
applicable well construction penults(Le.UIC,Conn ,State,Variance,etc.) ft ft,
in.
3.Well Use(check well use): ft. it in.
Water Supply Well: 17.SCREEN
;Agricultural FROM TO' DIAMETER SLOT SIZE THICKNESS MATERIAL
icipal/Public ft ft in.
*.Geothermal(Heating/Cooling Supply) Mftesidential Water Supply(single)
a lndustrial/Commercial Residential Water Supply ft it m
a Irri:anon PP y 18.GROUT
FROM TO Non-Water Supply Well: MATERIAL EMPLACEMENT METHOD&AMOUNT
*Monitoring Recovery25 ft -IyaCi P
Injection Well: ft. ft (I
*Aquifer Recharge [jGmundwaterRemediation ft. ft
*Aquifer Storage and Recovery EjSalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
Aquifer FROM TO MATERIAL EMPLACEMENT METHOD •StormwaterDrainage ft ft.
a Experimental Technology OSubsidence Control
$t Geothermal(Closed Loop) Tracer ft. ft.
t 'Geothermal(Heating/Cooling 20.DRILLING LOG(attach additional sheets if necessary)
(Heatin Coolin Return) *Other(explain under#2I Remarks) FROM TO DESCRIPTION(rotor,hardness,soil/rock
ft type.grain size,etc.)
4.Date Well(s)Completed: too rt r l U
Well ID# C2Q ft n
5a.Well Location: / (� �/r�,
�
-� 1roO ft IC.) ft g. 5aI G y` i(
—I- P +P r�P ors n /0 ft' 'r7 ft
Facility/ oerName �[Q(�, �((Yp�(j�P
Facility1D#(if applicable) 1?5 ft {t
l a o19 ec rp�>r, .• �/ � �UP !t i'N1i�P.
Y1P(i1?c ft.Physical Address,City,and Zip ;
ft. ft IR`x�:�„ ;
21.REMARKS _
County Parcel Identification No.(PIN) A��R .® LL�[J
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well geld,one laHiong is sufficient) . 11 i ; f.J 1,f.,:
o t n �O o , 22.Certif lion: ; `a'� i ��L `
N r17. W
6.IS(are)the well(s)I Permanent or _Te•
�; �� '"mporary Signature of Certified Well Contractor -
Date
7.Is this a repair to an existing well: yes or No By signing this form,I hereby eertijy that the well(s)was(were)constructed in accordance
gilds is a repair,fill out known well construction formation and explain the nature ofthe copy of this cord leas been provided to the well owner.0 02C.0200 e11 Construction Standards and that a
repair wider#21 remarks section or on the back ofthis form.
•
23.Site diagram or additional well details:
B.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
)led: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: �- SUBMITTAL INSTRUCTIONS
For multiple wells list all depths fdffere different(example-3@20'd ZQI00') (R) 24a• For AR Wells; Submit this form within
construction to the following. 30 days of completion of well
10.Static water level below top of casing:__ /U/Q
110 Staater tic el is above el use (ft) Division of Water Resources,Information Processing Unit;
11.Borehole diameter: (9 (in-)
Mail Service Center,Raleigh,NC 27699-1617
(in-) 24b.For Ini�on WeRs: In addition to sending the form to the address in 24a
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELD ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test:
'_'�t 24e.For Water Su v&Injection Wells: In addition to sending the form to
13b.Disinfection type: [�Y� Q�� the address(es) above, also submit one copy of this form within 30 days of
Amount: 1(00Z completion of well construction to thel county health department of the county
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-c2-201 6