GW1--03358_Well Construction - GW1_20230515

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7L L CONSTRUCTION RECORD(Gw R) . . .
For Internal Use Only. ---------- _ ___.-_.-
1.Well Contractor Information:
David Belcher `
14.WATER ZONES
Well Contractor Name FROM TO ➢ESCRIPrION
4594-A u ft tt
fL ft NC Well Contractor-Certification Number
Aqua Drill, Inc. 15.OUTER CASING for multicasedwells ORL YER(ifa livable)
FROM TO DIA.'VIETER THICKNESS MATERIAL
Company Name ft ft in.
J)Ra/ ^U
16.INNER CASING OR TUBING• eothermal closed-loo
2.Well Construction Permit#: I FROM To DIAMETER TffiCKNESS List all applicable well construction p MATERIAL
ermits(t_e.UIC,Comity,State,Variance,etc.) ft. &
in.
3.Well Use(check well use): ft ft is
F
Supply Well: 17.SCREEN
cultural FROM TO SLOT SIZE TInCK�Ss MATERIALtctpallPublic ftft. in.hermal(Heating(Cooling Supply) Residential Water Supply(single)strial/COMMercial R' in'
Residential Water Supply(shared)ation 19.GROUFROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: nitoring Recovery oC on Well: ft ft.
ferRechazgt DGroundwaterRemediationfer Storage and Recovery nSatinity Barrier 19.SAN1D/GRAVEL PACK tf a ticableTO
fer Test TL EMPLACEMEPIT MhT1IODOStormwaterDrainage ftrimental Technology Subsidence Controlftermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets ifhermal(Heating/Cooling Retutn) _.Other(explaia under#21 Remarks) FROM To DFscluPTtor1 color,bardness soiurock
Oft nO ft S^rain size,etc.
4.Date Weil(s)Completed: '-q' �. Wen IN O ft OC
5a.Well Location: fL ft i
Tref1P � i11�� ft '�
Facluty/Owner Name k Faci (ifpplicbie) t a ICI , e
Je%
I p �
220271
ft. t
PbysicaI Address,City,and Zip
4•IpKe_ L t� Q 21.REMARKS
County Parcel Identification No.FN
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
%6 h 1 N 4 I�e� Uf Jr�� 22.Certification:
6.Is(are)the well(s) Permanent or oTemporary
Stgnatme of CertrGed Well Contractor Date
7.Is this a repair to an existing well: Yes or No By signing this form,I hereby certify that the well(s)was(were)constructed fit accordance
rephisair
is a repair,julren out knottm well construction information and explain the nature ofthe copy ofthis record2C.0100 or s been profwded to the well owner.Well Construction Standards and that a
repair under#21 remarks section or on the back ofthis 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:
MIT
9.Total well depth below land surface: SUB TAL INSTRUCTIONS_- (I(5 00
For mttluple wells list all depths lfdii ferent Auunpk-3@200'and 2Q1003 24a.For All Wells: Submit this form within 30 days of completion of well
10.Static water level below fop of easing:_r construction to the following:
Ifivater level is above caring use-+" (ft.) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:_ (0 (in.) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.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.) construction to the following:
EPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
I636 Mail Service Center,Raleigh,NC 27699-1636
Method of test:�}C(1 �� rR 24c.For Water SunDly&IniectiA Wells: In addition to sending the form to
type: Amount the address(es) above, also submit one copy of thus form within 30 days of
-_ �[oFjy completion of well construction to the County health department of the county
where constructed,
Form GW-1 North Carolina Department ofEnviror ental Quality-Division of WaterResouroes
Revised 2-2_'-2r3.t6
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