GW1-2023-02974_Well Construction - GW1_20230425

WELL CoNsTRUCTION RECORD(GW b)
For Internal Use Only: � -
1.Well Contractor Information:
David Belcher
14.WATER ZONES
WellConhactorName - FROM TO DESCRIPTION
4594-A p ft ft
NC Well Contractor Certification Number ft
Aqua Drill, Inc. 15.00TERCASING £ormniticasedwells ORLINER ifa liaable)
FROM TO DIAMETER THICKNESS MATERIAL
CompattyName O ft 5g ft m, I LUC
t7�l 16.INNER CASING ORTUBING eothermal closed-loa ) r 2.Well Construction Permit#: s ,.h (C YCou FROM TO DIAMETER TH1cxivESs MATERIAL
List all applicable well construction permus�.e UIC,Count} State,Variance,etc..) fr. ft, in,
3.Well Use(check well use): ft ft 11L
Water Supply Well: 17.SCREEN
Agricultural FROM TO DIA1%1ETER SLOT SIZE THICKNESS MATERIAL
rcrpai/Public ft
Geotherm ft. in.al(Heating/Cooling Supply) Residemial Water Supply(single)
Iudustrial/Commenc➢al ft ft in.
_ Residential Water SnPP1Y(shared}
Irri ation IS.GROUT
FROfli TO MATERIAL EMPLACEMENT METHOD&AMOUNr
Non-Water Supply Welt: ft. u ft (,�
[Aquifer
itoring . Recovery tt 'E t
ion Well: ft ft•
ifer Recharge GroundwaterRemediation % �
ifer Storage and Recovery 0Sal�Barrier 14.SAND/GRAVEL PACK rf a liable
FROM TO MATERIAL, EMPLACEMENT METHOD
Test OStormwater Drainage ft ft
Experimental Technology oSubsidence Control % ft
Geothermal(Closed Loop) OTmcer 20.DRILLING LOG attach additional sheets if nec
:)Geothermal(Heating/Cooling Retum - H'Other(explain under#21 Remarks) FROM TO DESCRT10N color,Garda soll/roek a ote
ft ft
©
4.Date Well(s)Completed:-� �1 well ID# ft ft
Sa.Well Location: 9 ft 4 ft
tatliP_I 1.)�nr�Sr)� 9$
Facility/Owner Name Facility ID#(ifapplicable) ft ft
P' 7
ft ft [e .s
Physical Address,Chty,and Zip ft rt
},9fl1 iarw ca } Ur~a
—unty I P_ 21.REMARKS 1i
County Parcel identification No.(PN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient)
7
o , ur
22.Certification:
W
6.Ys(are)thewell(s) ._ Permanent or Temporary Signanaeof fiedWellContmctor ��-I�-"?�
Date
7.Is this a repair to an existing well: By signing this form,I hereby certify that the wells)was(were)constructed St accordance
Yes Or �/No with ISA NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe cOpY of this record has been provided to the well omien
repair under#21 remarks section or on the back of thisform.
23.Site diagram or additional well details:
8.For Geoprohe/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 I GW-1 is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional
drilled: Pages if necessary.
SUBidIIT1'AL INSTRUCTIONS
9,Total well depth below land surface:
For multiple wells list all depths ifd fferent(example-3@200'and 2@100� 24a- For All Wells: Submit this form within 30 days of completion of well
construction to the following.
10.Static water level below top of casing: y0 (ft.
If ivater level is above casing,use'+ ) Division of Water Resources,Information Processing Unit,
Il.Borehole diameter:
1617 AW Service Center,Raleigh,NC 27699-1617
(�) 24b-For Injection Wells: In addition to sending co the form to the address in
12.Well construction also submit one py construction method: f'1p�Y1c� f�,� of this form within 30 days of completion of well
(i.e.auger,rotary,cable,directpush,etc_) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276991636
13a.Yield(gpm) (Q Method of test: `({t►l� 24c.For Water Suanly&Injection Wells: In addition to sending the form to
13b.Disinfection type: � �rH�1 0 the address(es) above, also submit'one copy of this form within 30 days of
Amount:_ �(0(9 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