GW1-2023-02802_Well Construction - GW1_20230417

• __ _+ viva atdUt'liiON RECORDG�g
For Internal Use Only
1.Well Contractor Information:
David Belcher
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
4594 A 95 IL ,pp
IL NC Well Contractor Certification Number ft. + �`
ft
Aqua Drill, inc. 15.OUTER CAS/NG(for multi-cased wells ORLINER if a FROM TO DIAMETER licable
Name O THICKNESS MATERIAL
ft. 35 ft G-a5 in w .
Z.Well Construction Permit#:�(��o205rj 16.INNER CASING OR TUBING :eother mal ciosed400,
ft.List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) FROM ft. THICKNESS
MATERIAL
3.Well Use(check well use): 1n. 1111111111
ft ft is
Water Supply Well:
;� 17.SCREEN
*Agricultural 1Clpal/Pab1iC FROM TO DIAMETER sLOTSIZE THICKNESS MATERIAL
*Geothermal(Heating/CoolingSupply) in. -
PP Y) esidentia[Water Supply(single)
®ilndustrial/CommercialResidential Water Supply(shared) 11111121.111111
ft
II;;Irri•.tion 18.GROUT
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
*Monitoring ft ft.
Injection Well: Recovery n}O f 14
ft
ft. ft
ii!'.uifer Recharge
*Aquifer Storage and Recovery
Remediation
�Y C=fSuetyBarrier 19.SAND/GRAVEL PACK tfa.,liable
ill FROM
Aquifer Test TO MATERIAL E
(�Stolmwater Drainage tft. MPLACEMENT METHOD
*Experimental Technology °S�bsidence Control
MMEINIMIIMENNIIII
1�i Geothermal(Closed Loop) ft.
�Tiacer 20.DRILLING LOG attach additional sheets if access
*Geothermal(Heating/Cooling Rearm
Other FROM(explain under#21 Remarks) TO DESCRIPTION color,hardness
ess,soil/rack e, siz ere.4.Date Well(s)Completed: _3 i (DC tla
Well ID# 1O ft ft
5a.Well Location: r
5 ft ft
rvi4 ft 1
Yt'P, tz�Ar�a
Facility/Owner Name ft
}} 1 Facility ID#(if applicable) ft. ft
Physical Address,City,and Zip .� _ -. 'tL..:•- .l
ft g,
. ,5_cP�h (LPLS a 1 I r 1
County
Parce!Identification No.(PIN)
longitude5b.Latitude and :- `- i=i Pr.:- .3l!r..;
in degrees/minutes/seconds or decimal d G '
(if well field,one lat/ong is sufficient) agrees: ;:%:JL
�(00 r rt N d 2 22.Certification:
W
6.1s(are)the well(s) permanent or °Temporary Signature of Certified Well Contractor -� °?3
7.Is this a repair to an existing well: °�-IyeS or Date
l NO By signing thus form,I hereby certify that the well(s)was(were)constructed hi accordance
If this is a repair,fill out known well construction information and explain the nature of the
copy of this record has been provided to the well owner.
with ISil NCAC 02C.0100 or IS�I NCAC 02C.0200 Pre!!Construction Standards and that a
repair wider#21 remarks section or on the back of this form.
238.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same '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 lannd surface: � suBnuiTAd.INSTRUCTIONS
For
Total
multiple wells list all depths differe+u(example_3@200'and 2@100q at-) 24a. For All Wells: Submit this form within 30 days of completion of well
10.Static water level below top of casing:`_� construction to the following:
If water level is above casing use"+" (ft)
Division of Water Resources,Information Processing Unit;
11.Borehole diameter: CO 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: '(.
(ie.a e rotary above,also submit one copy of this form within 30 days of completion of well
ug tat cable,directpush etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
13a Yield(gpm) 1636 Mail Service Center,Raleigh,NC 27699-1636
Method of test: fkj±7 p1P 24c.For Water Su v&Injection Wells: In addition to sending the form to
13b.Disinfection type: `gyp% the address(es) above, also submit one co
Amount: completion of well construction to the county health department of this f 30
edcou of
nty
where constructed
Form GW-1
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016