GW1--03359_Well Construction - GW1_20230515

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W)E1TLL CO IS FC'111 N RE ORD GW-y '
For Internal Use Only. -- - - - -
L Well Contractor Information:
David Belcher
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
4594-A it �a ft:
r
NC Well Contractor Certification Number fL fL
Aqua Drill, Inc. IS.OUTER CASING for multi-eased wells OR LINER if livable)
FROM TO DL4'HETER TiHCKNESS MATERIAL
Company Name O it ( ft ^ ,
2.Well Construction Permit#: �C,)a 1 16.INNER CASING OR TUBING eothermal dosed-loop) Tw
List all applicable well construction permits(I.e.a L;,County,State.Irariance,etc•) FROM fL TO ft.
ETE DIAMR in. THICKNESS MATERIAL
3-Well Use(check well use): ft ft in
Water Supply Well: 17.SCREEN
Agricultural icipaliPublic FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Geothermal fL fL in.
(Ileatir- e
glCooiing Supply) Residential Water Supply(single)
triaUCommercial fL ft. in.
Residential Water Supply(shared)
tion 1&GROUT
Non-Water Supply Well: �oai TO MATERIAL nEMPLACEMENT METHOD&XVIOUN I
ft. r
oring Recovery n Well: ft ft
er Recharge OGaoimdnaterRemediationft fter Storage and Recovery SalinityBafflr 19.SAND/GRAVEL PACK if a livableer Test FROM TO MATERIALEMPLACEMENT METHOD
StomrwatrDrainage ft gtimental Technology Subsidence Control fternal(Closed Loop) Tracer20.DRII LING LOG attach additional sheets if necessa
rmal(Heating/CooIing Return) _ Other(explain under#21 Remarks) FROM To DESCRIPTION Color,hardness,mtl/rock a tarn s z etc.
Q ft 4.Date Well(s)Completed:_ Jr•o�-GQ 3 Weil UN It C I
fL
O ft It
5a.Well Location:
!1I fL I ft t.
FaeilitylOcvnerNam Facility! w(if applimble) ft "R6
fL
ft. ft
Physical Address,City,and Zip ft. gt
S}�uPS 21.REILIARKS MAY 1 073
County
Panel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:.(ifwell field,one lat/long is sufficieut)
GO 31 r �{ 1 Of 22.Certification:
6.Is(are)the well(s) ermanent or i t7L i< 5-2
Temporary SlgnatnicofCeitrfied Well Contractor-7— Date +-�-�-
7.Is this a repair to an existing well: DYes or BY stSning this form,I hereby certify that the well(s)was(were)constructed in accordance
If this is a repair,fill out larown well construction information and explain the nature ofthe with 15A NCACis 0 C.01 provided to the well owner.0 e11 Construction Standards and that a
rem
repair under#21 arks 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 of drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: SUBMITTAL INSTRUCTIONS
For multiple wells list all depths ifdiiferent(example-3@200a d 2(Q100� ( ) cons For_ n t Wells; Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: roll
Ifwaterlevel is above casing,use"+^ (ft.) Division of Water Resources,Information Processing Unit,
Il.Borehole diameter:_�O
1617 Mail Service Center,Raleigh,NC 27699-1617
(n.) cobs For Iniection WeOs: In addition Ito sending the form to the address in 24a
12.Well construction method: h,
rotary,cable,direct above,also submit one copy of this form within 30 days of completion of well
lie_auger, push,etc.) construction to the following:
EWATERUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
3 Method of test:�tz4eh � e 24c.F r ter Suualy&Iniection Wells: rn addition to sending the form to
type: i
Amount: ([4iOZ the addresses) above, also submit one copy of this form within 30 days of
completion of well coastruction 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-ZO7 C.