GW1--03776_Well Construction - GW1_20230602

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WELL CONSTRUCTION RECORD(GW-,I,) For Internal Use only: -` ---"
1.Well Contractor Information:
fDavid Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A fr• rt cx
fr. ft.
NC Well Contractor Certification Number
IS.OUTER CASING for multi=rased well OR LINER(IfalmHvable
Aqua Drill, Inc. FROM I TO DIAI MTEft I THICKNESS AfATERlAL
j Company Name ft. ft. in. INC
16.INNER CASING OR TUBING eothermal dosed-too '
2.Well Construction Permit#: I I FROM I70 DIAMETER TMCM14F MATERIAL
List all applicable well construction permits(i.e.UIC,Conn%State,Variance,etc.) fr. ft. ft
1
3.Well Use(checklvell use): fr. %
Water Supply Well: 17.SCREEN:
' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public fr. ft
j Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. fr. In.
Industrial/Commercial Residential Water Supply(shared)
"18.GROUT
j hri atiOII. FRO51 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fr. ft
Monitoring Recovery fr. IL
i Injection Well:
Aquifer Recharge oGroundwater Remediation ft.
Aquifer Storage and Recovery D tY Salini Barrier 19.SAND/GRAVEL PACK if applicable),
. ,
<=1' FROM TO MATERIAL EMPLACEMENT METHOD
Agtrifer Test oStormwater Drainage ft.' ft
Experimental Technology (Subsidence Control fr ft
& Geothermal(Closed Loop) OTracer :20:DRILLING LOG attach additional sheets tinecessa -.
Geothermal(Heating/Cooling Return) n Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardnm saiUruck type, ra n siu etcJ
ft, ft.
j 4.Date Well(s)Completed:-Jam' 9-a Well ID# ft., it.
5a.Well Location: ft. it
i4
/� inn' CYibSD ft. ft.
Facility/Owner Nome Facility ID#(if applicable) ft. fLaAL
( I�r u. ft
Physical
hy_ Address,City,and Zip ft ft JUN V � L L J
OSt I1 21.REMARKS •..
County Parcel Identification No.(PIN) ttt�ri µ's ✓1 =rf4^C3t!!4� t.t
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one]at/longis sufficient) 9� r1 22.Certification
Permanent or TempoWNo
Signature ofCemfi weu Contractor Date
6.Is(are)the well(s)f...
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an ezisting well: E3Yes or with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Welt Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 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 ofwclls construction details. You may also attach additional pages ifnecessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface:-COy (ft) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2Q1000 construction to the following:
10.Static water level below top of casing: (40 (ft) Division of Water Resources,Information Processing Unit,1f water level is above casing,use"+" g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: c_(in,) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: (( A;( 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:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)— a Method of test: �(�()r1 - ,.mp 24c.For Water Supply&Injection Wells: In addition to sending the form to
136.Disinfection type: 1171-I 70
o the address(es) above, also submit one copy of this form within 30 days of
/o Amount _ an 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