GW1-2023-02800_Well Construction - GW1_20230417

1® I
FOr Internal Use Only:
1.Well Contractor Information:
David Belcher
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
4594 A 1-1/0ft 416
NC Well Contractor Certification Numbert �{
ft.
Aqua Drill, Inc. 15.OUTER CASING for multi-cased wells OR LINER if a. licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name Q ftMaln/ ' Pal
16.INNER CASING OR TUBING .eothermal closed-too.)
2.Well Construction permit#;
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) FROM ft DIAMETERTOrr'u�ri`rsX'� MATERIAL
in
3.Well Use(check well use):
R ft. in. —
Water Supply Well: 17.SCREEN
11•AgnculturalFROM TO DIAMETER SLOTSiZE THICKNESS MATERIAL
*Geothermaltcntial ft ft. in.(Heating/Cooling Supply) dentiai Water Supply(single) —
MI lnndustri Supply(shazed)
allCommercial DResidential Water ft. in. -
MiItri:ation 18,GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENTMETAOD&AMOUNT
*MonitoringQ ft' ..a ft. n
Recovery )'Ilotc t,' ' Yu - '11 a Cs -
Ei
Injection Well: ft. ft.
*Aquifer Recharge OGroundwaterRemediation
eeble
*Aquifer Storage and Recovery °Salinity Barrier 19.SANDIGI3To PACK>f a MATERIAL
*Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD
l.,,Stormwater Drainage IL
*Experimental Technology DSubsidenceControl
*Geothermal(Closed Loop) OTracer R' ft
Geothermal 20.DRILLING LOG attach additional sheets ifnecessa
(Heating/Cooling Return) *Otter(explain under#21 Remarks) FROM To ,hardness,sovroctc
4-/0.- .ft ft. DESCRIPTION color,hardn 3 S sir etc
4.Date Well(s)Completed: _ Well lD#
ft ft
5a.Well Location: t
N7 ft
O�a�tP GO ft"
t y� ,
FacilitplOwnerName Facility ID#(if applicable) ft. ft
,
��i tQfv1S t^ l.P/ )iSi�rllp /l)i ��7nt 3 ft ft
Physical Address,City,and Zip �—
County ZL REMARK,c
Parcel Identification No.(PIN) l 1 n i
5b.Latitude and longitude in degrees/minutes/seconds or decimal d
(if well field,one lat/longissufficient) degrees:
i;,;Gi:: ;'.,.1 .-1 ;it_„
AU1 I r Ir N q—go° aR, �� ' 22.Certification: `�'•A ,'?i.-
W
��.r
6.Is(are)tne'well(s)�Fermanent or r ar �
Tern or Signature of Certified Well Contractor Date
Yes or By signing this form,I hereby ant,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well:
MAC 02C
Ifthis is a repair,fill out known well construction information and explain the nature of the copy ofthiswith ISA reecord has been proC 02C.0100 orf54 ded to the well own0er Well Construction Standards and that a
repair under#21 remarks section or on the back ofthisform.
23.
8.For Geoprobe/DPT or Closed�Loop Geothermal Wells having the sameYou Site diagram
back of thipageadditional well
provide additional well site details or well
construction,only 1 GW-1 is needed- Indicate TOTAL may
drilled: NUMBER ofwells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface;� - 11 U� SUBMITTAL INSTRUCTIONS
For multiple wells list all depths tfdifferetn(example-3(a3200 and 2@f00� (f-) 24a. For All Wells: Submit this form within 30 days of completion of well
•
10.Static water level below top of casing: TiO construction to the following:
If water level is above casing,use"+" (ft.)
Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (0 1617 Mali Service Center,Raleigh,NC 27699-1617
(in.)
24b.For IniecHon was: In addition to sending the form to the address in 24a
12.Well construction method: ��r0 A;(` above,also submit one copy of this form within 30 days of completion of well
(in.auger,rotary,cable,direct push etc.) construction the following
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)___1a 1636 Mail Service Center,Raleigh,NC 276991636
Method of test:_ o�
{(� .'T rna 24c.For Water Supply&Injection Wells: In addition to sending the form to
13b.Disinfection type:- NTN rlbolo Amount: ( the address(es) above, also submit one copy of this form within 30 days of
�t9` completion of well construction to the county
where constructed, health department of the county
Form GW-1
North Carolina Department ofEnvironmental Quality-Division of Water Resources
Revised 2 22-2016