GW1--04133_Well Construction - GW1_20230623

WELL CONSTRUCTION RECORD(GW.1) For Internal Use Only:WELL Form
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A NO fr' n NI Ir. a C•c4��{I( cpzku.Cel
NC Well Contractor Certification Number atO0 e. aU ft iQ GM (rsr�ekuce
:3 15.OUTER'CASING'(for multi-cased wells)OR LINER(if op licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKN�EISS MATERIAL
Company Name 0 ft. n ft' GA in" Sigig1 I CVC
�" I-f,� n 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: E�ik) c20210 t-O05 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft ft in.
3.Well Use(check well use): ft. ft. in.-
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural unicipaVPublic ft ft. in.
Geothermal(Heating/Cooling Supply) rLI Residential Water Supply(single) R, ft in.
QIndustrial/Conunercial ['Residential Water Supply(shared)
_ 18.GROUT i
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft , 4 �u)(dte_
[Monitoring Recovery 0 ft al ft �en�onrEe YOU[ Cl(1't�S Qr
Injection Well:
DAquifer Recharge [jGroundwaterRemedjation ft ft
tufer Stora a and Recovery 19.SAND/GRAVEL PACK(if applicable)' '
A
q g ry C3ISalinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
DAquifer Test DStormwater Drainage 11. ft
Experimental Technology ['Subsidence Control ft ft
Geothermal(Closed Loop) Tracer 20:DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(altar,hardness,sell/rock lrock type,grain size,etc.)
0 ft 10 Cla
. 4.Date Well(s)Completed: 6-)3•o3 Well ID# 10 ft. 3e2 ft. iiy11,, Swot[ so,l •
5a.Well Location: 3a ft• 3'7 ft u//e (�_ /hike
()lad Awn. • S7 ft' a$5 ft I S1 , 117---C.t I!- i.'
lice &r1ttt RECE: ,/E
Facility/Owner Name Facility ID#(if applicable) ft ft
/O3 cleg71 4 1•,Qne1 flerJsu;Ire,MCa73,,lo ft. ft JUN SsZU"L3
ft ft
Physical Address,City,and Zip
1�1i11 }ZnOI 21.REMARKS .•
{thy:n: Cl �l s�•s:�V ,[rr
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3r ay' 49.a" N Yq d Ind' '9.r" W (i . 6,-/ya3
6.Is(are)the well(s) Permanent or Temporary signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or sio with 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under#21 remark 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: P 5 (B.) 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@l00) construction to the following:
10.Static water level below top of casing: 40 (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: CD (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
(,1 _,__' J�'(, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: fst Alit !„
(i.e.auger,rotary,cable,direct etc.) construction to the following:
au r push,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 14 Method of test: Cole[[\ 4 Tone 24c.For Water Supply&Injection Wens: In addition to sending the form to
17 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1.-rt-t�]B t'6 Amount: 'COI completion of well construction to the county health department of the county
where constructed.
' I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016