GW1-2023-02946_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD(GW fl) For Intemal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A 1,55 fx 159 ft _J0 um
ft ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells OR LINER if a livable
Aqua Drill, Inc. FROM TO DIAMETER FTFHCKNESS MATERIAL
Company Name ft. 60 It- 5 In. %%a 1 YVC.
M INNERCASING OR TUBING eothermal doseddoo
2.Well Construction Permit#: 3591214 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits C.a.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural tclpal/Public ft ft. in.
Geothermal(Heating/Cooling Supply) BRcsidential Water Supply(single) ft g• in
Industrial/Commercial DResidential Water Supply(shared) 1&GROUT
11Ii ation FROM I TO MATERIAL EXUPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft It.
, T10C
Monitoring DRecovery R, g•
Injection Well:
ft ft
`. Aquifer Recharge E)GmundwaterRemediation
Aquifer Storage and Recovery S Barrier 19.SAND/GRAVEL PACK if a liable
ahnrty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ! Stormwater Drainage ft ft
Experimental Technology OSubsidence Control ft ft
f�lGeothermal(Closed Loop) OTmcer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeaUng/Cooling Return) nOther(explain under#21 Remarks) FROM To I DESCRIPTION color,hardness,sotvrock type,grAIn etr:
Q ft ft
4.Date Well(s)Completed: y I7-, ?i Well ID# 50
ft
5a.Well Location: 50 ft 155 ft
ft ft. 77
Facility/Owner Name Facility ID#(if applicable) ft ft ( ® ®
�u5 nl�trrlrz�� 1n 9i (�c1�' Lk'9 IN ft
� 6 nu 9. � 7023
Physical Address,City,and Zip ft ft JAI
IRIS
21.REMARKS
County1r Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
350 ao' 63-'g­ » go0 ad 1' W
6.Is(are)the well(s)dermanent or OTemporary Signature ofCettifi ell Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.YS this a repair to an existing well: 0Yes or No with ISA NCAC 02C.0100 or 15A NCAC 02C_0200 Nell Construction Standards and that a
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.
repair under#21 remarla section or on the back of this form.
23.Site diagram or additional well details:
8.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 construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: _ 24a. For All Wells: Submit this form within 30 days of completion of well
For mtdtiple wells list all depths ifdifferent(example-3 a200'and 2@1009 construction to the following:
10.Static water level below top of casing: Ll d (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 (in) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
22.Well construction method: _®}� above,also submit one copy of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct push,etc.) i] construction to the following:
FOR WATER SUPPLY WELLS ONLY: U Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: (rkk\'L JIplC 24c.For Water Suppiv&Injection Wells: In addition to sending the fors to
a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH 90 lD Amount I(oor- completion of well construction to-the county health department of the county .
where constructed.
Form GW-1 North Carolina Department ofEnvironmental Quality-Division of Water Resources Revised 2 22-2016