GW1-2023-02973_Well Construction - GW1_20230425

WELL CONSTRUCTION RECORD GW-1 I�_........_.,...,
For Internal Use Only:
1.Well Contractor Information: I{
David Belcher
Well ContractorName 14.WATER ZONES
FROM TO DESCRIPTION
4594-A 340 ft 34S ft 10 GPM()rtacAtwe)
, NC Well Contractor Certification Number R
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FR//O��M TO DIAMETER cTHHIIC�KNESS. MATERIAL�j
V
Company Name )Q( f Cp.�J� in. �tlllp�1 ?VC
2.Well Construction Permit#: 390 �Q 16.INNER CASING OR TUBING(geothermal closed-loop)
List all applicable well construction permits(Le UIC,County,State,Variance,etc.) FROM TO DIAMETER THICKNESS MATERIAL
ft. ft in.
3.Well Use(check well use): ft.
in.
Water Supply Well: 17.SCREEN
*'Agricultural tcrpal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
.Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single)
*Industrial/Commercial ft in.
Residential Water Supply(shared) 18.GROUT
Irrigation
Non-Water Su l Well: FROM TO MATERIAL EMPLACEMENT METHOD&AtiMOUNT
PP y 0 ft ft t*Monitoring Recovery 'i)farYlnnl}e C4U(' C�1�p5 4-W _d(tP
Injection Well: ft.
*1 Aquifer Recharge DGmundwaterRemediation ft
i Aquifer Storage and Recovery Ej Salinity Barrier 19.SAND/GRAVEL PACK(if applicable)
MP
*Aquifer Test FROM TO MATERIAL EMPLACEMENT METHOD IDStormwaterDrainage ft
*Experimental Technology, EPubsidence Control
ft. ft.
*Geothermal(Closed Loop) OTmcer
INI Geothermal(Heating Cooling 20.DRILLING LOG(attach additional sheets if necessary)
e/ o Return) QtOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soilirock type,grain size,etc.)
6 IL ah ft I
4.Date Well(s)Completed: Li-19'c&3 Well ID# aOSa.Well Location: ft. �� ft. San S��l
Coo ft9C0 ftSemeg Sc,,[
Aoc',10wPn 4Ca f' VA ft.Facilihr/Owner Name 'blue. (�4f ,�e
Facility ID#(if applicable) 101 ft 3g5 ft.
(4
_a t(1PC � / s2r kc,I'I1e�-�� I ft )1UP �t(Ql)i4t�� {'N p+*ra..,,'t
Physical A dress,City,and Zip `�
r n ft: APR 2 S'�dl)�P �-7310666tX4Q 11.REMARKS LO�
County Parcel Identification No.(PIN)
k>iaas3tion Pmcam Unit
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
0 �. I,a.q t, 22.Certification:
N Sow 3$' 3.5" W
D'c90-
6.Is(are)the Well(s) ermanent or Temporary Signature of Certified Well Contractor
Date
7.Is this a repair to an existing well: OYes or No By signing this form I hereby cert05,that the well(s)was(were)constructed in accordance
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record hasObeen provided 100 to tlrwell owner.or 15A NC 02C Well
Construction Standards and that a
repair under#21 remarks 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: 'qb
For multiple wells list all depths ifdifferent(example-3@200'and @I0O) ( ) For All Wells: Submit this form within 30 days of completion of well
ons c
construction to the following:
10.Static water level below top of casing: 50
If water level is above casing use"+' (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: (A1617 Mail Service Center,Raleigh,NC 27699-1617
(in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
d(� ��C
12.Well construction method: above,also submit one copy of this form within 30 days of completion of well
(ic.auger,mtary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I 0 Method of test: Cocklq 4-7:MP 24c.Far Water SnpD1y&Injection Wells: In addition to sending the form to
13b.Disinfection type:jlYt{ the address(es) above, also submit one copy of this form within 30 days of
Amount: IGOZ. completion of well construction to the county ty health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvimnmental Quality-Division of Water Resources
Revised 2-22-2016