GW1--04062_Well Construction - GW1_20230622

Prlrif Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
David Belcher :14.WATER ZONES i;, _ .
Well Contractor Name FROM TO DESCRIPTION
4594-A 9© ft• 95 it. Ia(OR (FCac4uit•)
ft. ft.
NC Well Contractor Certification Number
O
Inc.
.15. UTERCASING'(for multi-cased wells)OR LINER(If ap licable)
Aqua Drill, c FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 67 ft. Co.
nC in' M'&i Tvc
r7 16.INNER CASING OR TUBING(geothermalclosed-loop):
2.Well Construction Permit#: t�g7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ff. f6 in.
3.Well Use(check well use): ft ft in.
Water Supply Well: :17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 0 'cipaVPublic ft. ft in.
*Geothermal(Heating/Cooling Supply) Di'Residential Water Supply(single) ft. ft. in.
DIndustrial/Conunercial DResidential Water Supply(shared) 18.GROUT
flhrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: Q it: as ft.
t Oils �-t-tyacate
nMonitoring ]Recove ` enfont�e /me
k ry ft. ft.
Injection Well:
DAferft. ft.
quifer Recharge �GroundwaterRerhediation
Aquifer Storage and Recovery Salmi Barrier 19.SAND/GRAVEL PACK(if applicable);
tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRILLING (attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,somracic type,grain size,etc.)
ft. ft
a0 0
4.Date Well(s)Completed: 6•!3-a3 Well ID# go ft. ( ft. 9i soil coo
5a.Well Location: _ Gc p9 EL
67
ft' I"♦41n &See
Tcec4 'P&ter (Q9 ft. 165 ft. Ilue &rangy
Facility/Owner Name Facility ID#(if applicable) ft. ft.
'c;n4ie }Rclr�5t)ille A)c.c7.3ao ft. ft. °�� "
f 1 ?' „ a .... ,. & .
Physical Address,City,and Zip ft. ft.
C45 11 21.REMARKS. - iiJ('i.9 "y-lit/i
County Parcel IdentificationNo.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C".,. nee
(if well field,one lot/long is sufficient) 22.Certification:
I7 1-119.3 N 79° RV' 3 ntr W JJl111GQ aal� 6.il(-a3
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form.I hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes oro with ISA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction injbrmation and erplain the nature of the 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:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IN il.DS _ (ft) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(Idifferent(example-3@200'and 2@a l00') construction to the following:
10.Static water level below top of casing: CIO (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use •+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (0 (in) 24h.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 01'07 XI' construction to the following
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) f a Method of test (r0i,i h 4 limp 24e.For Water Sunnis,&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1-fl14 70% Amount: 1(Qp1_ completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources , Revised 2-22-2016
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