GW1--03530_Well Construction - GW1_20230519

WE L COIvIS�'It1 FC N RE-'ORD GW-1 .
For Internal Use Only. - - -- ---
1.Well Contractor Information:
David Belcher
Well Contractor Name 14.R'ATER ZONES i
FROM 4594-A TO DESCRIPTION
70 ft 7a ft
. re
NC Well Contractor Certification Number ft. ft
Aqua Drill, Inc. IS.OUTER CASING for multi-cased wells OR LINER tfa cable
r FROM TO DIAMETER THICKNESS MATERIAL
' Company Name 0 it. m ��
16.INNER CASING OR TUBING(eothetmal closed-loo )
2.Well Construction Permit#: © ?(1']
List all applicable well construction FROM TO DIAMETER THICKNESS MATERIAL
pemm�ts(>.e,il(C,County,State.Variance,etc) fl: f4 in.
3.Well Use(check well use): ft. ft.
in.
Water Supply Well: 17.SCREEN
Lte
cultural icipal/Pablic FROM TO DIAMETER SLOTSIzz THICKNESS MATERIAL
ermal ft fL in.
(Heating/Cooling Supply) Residential Water Supply(single)
strial/Commercial % ft.Residential Water Supply(shared)tion I8.GROUT
ater Supply Well: EOMTO MATERIAL EMPLACEMENT METHOD&AMOUNT
ft t
toring Recovery T on Well: ft. ftfer Recharge oGroundwaterRemediation R fL
er Storage and Recovery g 19.SANPACKer Test almlty BarrierFROM TO . EATMETHOD
StormwaterDrainage ft.imental Technology Subsidence Contmlermal(Closed Loop) Tracer fk ft.
ermal 20•DRILLINGLOG attach additional sheets ffnecessary
(Iieating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rack grain sh etc.,
it. ft
4.Date Well(s)Completed: �,/ e•o� Well ID#
ft ft �
5a.Well Location: ft R
ft. %
Facility/Owner Name 0
FacilityID#(ifapplipble) ft ft. 1.
ft G J tr
Physical Address,City,and Zip IL 1+
fL ft
2L REMARKg
County ..
Parcel Identification No.(PIN)
rl �2�
56.Latitude and longitude in .t!O nt
(if well field,one laUlong is degrees/minutes/seconds or decimal degrees:
saflicient) "
22.Certification:
6.Is(are)the well s — `- ���a .r&
O'._.. Permanent or �ITemporary Signature ofCemfied Well contractor
Date
yeS or By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an esisling~veil:
Ijrkrs is a repair,fill out known well construction information and explain the nature of e opt oftlliswith 15A �ecord h os been prowled to the well owner.
e11 Construction Statulards and that a
repair under#21 remarks section or on the Lack ofthis form,
23.Site diagram or additional well details:
construction,,Only For Geo DPT or Closed-Loop Geothermal Wells havingthe same You may use the back of this page to provide additional well site details or well
c 1 GW-1 is needed indicate TOTAL
drilled: NUMBER of wells construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: 1�� SUBMITTAL INSTRUCTIONS
m
For ultiple wells list all depths ifdifferent(erannple-3@200 and 2@100�1 00 24a. For AII Wells:
�--__ Submit this form within 30 days of completion of well
10.Static water level below top of casing:__ construction to the following:
Ifwater level is above caring use '+" (ft•) Division of Water Resources,Information Processing Unit,
11.Borehole diameter: 1617 Mail Service Center,Raleigh,NC 27699-1617
(�) 24b.For IDiectiOn Wells: In addition to sendingthe form to the ad
12.Well construction method: ' r above,also submit one co dress m 24a
(i.e.auger,rotary,cable,direct push,etc.) constriction to the following: of this
form within
30 days of completion of well
EDidnfection
PPLY WELLS ONLY.• Division of Water Resources,Underground Injection Control Program„
1636 Mail Service Center,Raleigh,NC 276991636
Method of test:� (� -��'
tmn 24c For Water SDDaIv&Iniection Wells: In addition to sending the form to
pe: }�'l�-� `74°/ the address(es) above, also submit one co of this form within 30 days Amount. Q/5L completion of well construction to the couny health de county
of
P tY
where constructed. department of the county
Form GW-1
North Carolina Department ofEnvironmental Quality-Division of Water Resources
Revised 2-22_2016