GW1--03607_Well Construction - GW1_20230522

i,co RECOR><➢ G�fl .. .
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1.Well Contractor Information: For Internal Use Only:
David Belcher
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPI'(ON
4594-A O rr.
NC Well Contractor Certification Number ft ft.
Aqua Drill, Inc. IS-OUTER CASING(for multi-casedwells ORLTNER ifa licable
FROM TO D1,411ETER THICKNESS MATERIAL
CompanyName O ft. C .n in.
2.Well Construction permit#:_2�go7 16.INNER CASING OR TUBWG eothermal closed-l0')
Lk-
List all applicable well construction permits r.a fit;Coimg;State.Variance,etc.) FROM ft, IL TO DIAMETER THICKNESS MATERIAL
in.
3.Well Use(check well use): ft. ft in.
[Nte
Supply Well; 17.SCREEN
Agricultural FROM TO DIMIETER SLOT SIZE THICKNESS MATE
RiAI
paUPubli ft ft in
thermal(Heating(Cooling Supply) SRyuaiel
esidential Water Supply
strial/Commercial PP Y(single) �Residential Water Suppply(shared)ation IS.GROUT
ater Supply Well: FROM TO MATERIAL EMPLACEMENT AILTHOD&AmouNT
itoringon Well: Recoveryfer Recharge Groundwater RemdiatioRRfer Storage and Recovery OSaiinilyBanier 19.SAND/GRAVEL PACK if a licablfer Test FROM TO MATERIAL EMPLACEMENT t11ETHOD
0Stormwat.Drainage ft ftrimental Technology Subsidence Controlt fL
ermal(Closed Loop) Tracerfermal(Heating/Cooling Return) 20.DRII LING LOG attach additional sheets if necessa
{ Other(explain under#21 Remade.) FROM TO DESCRIPITON color,61rdaes4 soluruckgpe,gridu size,etc
4.Date Wells)Completed: l Well ID# O ft Oft
5a.Well Location: ft.
iG
ft: I ft. lu 'I
FacihtylOwnerName Facility ID#(ifapplicable) ft ,
5 ft:
ll r1C' I1�QQ��iPlr , 1/ /T//"lrin
Ph Address,
yslcal City,and Zip ft. It.
It
21.REMARKS `� q
County
Parcel Identification No.(PN zs
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: y
(if well field,one Iat/long is sufficient)
„ 22.Certification:
E 9
� SUS.?I' 37 U
6.Is(are)the well(.) Permanent or
TemporaW—N.
Signature of Certified Well Contractor
Date
7.Is this a repair to an eidstingwell: }Yes of with
signing this form,1 hereby certfy that the well(.)was(were)constructed in accordance
IJthis is a repair,fi/1 out knorm well constriction information and explain the nature ofthe apY oftT»s record lips beeno roI SA NCA a 1YQ'200 Well Construction Standards and that a
repair under#21 remarks section or on Ore back ofthu 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 construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary. or well
drilled:
9.,Total well depth below land surface: 1J 94 3UBMFTTAL INSTRUCTIONS
too
For nadtiple wells list all depths ifd fferent(erarnple-3 00'and 2@1001 (ft 24a•For All 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 casing use .+,• (ft) Division of Water Resources,Information Processing Unit,
11.Borehole diameter:_ G (m•) 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:�Ej{apt k r above,also submit one copy of this foray within 30 days of completion of well
(Le.auger,rotary,cable,direct push,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(gpmj_ Method of test: �n(Ci'1 � �;ma 24c.For Water SuDDIv&Injection Wells: In addition to sending the form to
13b.Disinfection type: the addresses) above, also submit one copy of this form
Amount �OZ: completion of well construction to the county health within 30 days of
where constructed, part of the county
Form GW-I North Carolina Department of-Environmental Quality-Division of Water Resources