GW1--03775_Well Construction - GW1_20230602

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WELLCONSTRUCTION RECORD(GW-1) For Intelnai Use only.I.Well Contractor Information:
David Belcher 14,WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A G ft* rut
ft ft.
NC Well Contractor Certification Number
15.OUTER CASING for multi-ased.wells OR LINER if a licable
Aqua Drill, Inc. FROM To DLUVIErER THIcrQrEss MATERIAL
Company Name ft. �I ft. in, S U�
r 16.INNER CASING OR TUBING eothermal dosed-loo
2.Well Construction Permit FROM TO DIAMETER THICKNESS MATERIAL '
List all applicable well cor struction permits(Le.UIC,County,State,Variance,etc.) fL ft in.
i
3.Well Use(check well use): ft it
Water Supply Well: .17.SCREEN '
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ViResidential
mtcipaUPublic ft, ft in.
Geothermal(Heating/Cooling Supply) Water Supply(single)
fL ft.
Industrial/Commercial E)Residential Water Supply(shared)
18.:GROUT, .
Inat II FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft LVI tt , �
Monitoring Recovery ft. ft '
Injection Well:
Aquifer Recharge ft. ft
q g Groundwater Remediation
Aquifer Storage and Recovery I�YStY Bye 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft• ft.
Experimental Technology Subsidence Control ft. ft
Geothermal(Closed Loop) OTrscer 20.DRILLING'LOG attach additional sheets if necessa
Geothermal(Heating/Coolin Retum) Other(explain under 421 Remarks) FROM TO DESCRD'T10N color,hardness soiUrock e, ram size,etc
O ft ft CC
4.Date Well(s)Completed: S-a?5 023 Well ID# Q ft. ft
ao
5a.Well Location: 33 ft ut %
Cm;kh y� ft ftAfe Facility/Owner Name Facility ID#(if applicable) Ct. ft. ,
l41 :fvnn'.4'Pr 1�(' �I,y'�Uille� Alt' ?7 ,Q0 fr ft.
Physical Address,City,and Zip it. % I 1'v
ins loll 21.REMARKS.,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 22.Ceriiticati n:
N 79° a8' O I" W
C2
6.Is(are)the wells) Permanent or oTemporary Signature ofCertified Well Contractor Date
By signing this fonts,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: oYes or No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction infonnation and explain the nature of the copy of this record has been provided to the well owner.
repair under#2I remarks 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 NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
C SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: e?(o 1 (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2®1000
wnstrction to the following:
10.Static water level below top of casing: 5Q (ft) Division of Water Resources,Information Processing Unit,
If water level is above casirig,use-+„ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CO (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 'iln+ary A'(' above,also submit one coley of this form within 30 days of completion of well
(Le.auger,rotary,cable,direct pusb,etc.) 01- construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:-(,CkYl -l',MN. 24c.For Water Supply&Injection Wells: In addition to sending the form to
o the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: i{-rl{ ��/o Amount, l(,oz- completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016