GW1--04424_Well Construction - GW1_20230710

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A 117c, ft* tri t ft* arm`)m (Frrrzclu m' •
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS() MATERIAL
Company Name 0 ft. 9a ft Co.r1L�rn. SIJKp7 1 t VC
/�n (�(y 16.INNER CASING OR TUBING(geothermal( tJ closed-loop)
2.Well Construction Permit#: OI©cY[X(�7iy FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. io.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
Agricultural FROM' TO DIAMETER SLOT SIZE THICKNESS MATERIAL
unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) .'18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. all
It. t�vrn;1p ?our Chrs mil- jdIb e
Monitoring Recovery • (/ ft. Ot-f ft. ,,G (J
Injection Well:
Aquifer Rechargeft.
9 Groundwater Remediation
Aquifer Storage and Recovery Salmi Battier 19.SAND/GRAVEL PACK(if applicable)
ty FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology J 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(color,hardness soil/rock
type.Rain size,etc.)
0 fr. t20 ft. Clay
4.Date Well(s)Completed:_a-I O.(93 Well ID# a0 ft.
V7 ft ( Sam 1t
5a.Well Location: q7 it c) ft 1ILte CyEintie
-Kell KP.1111Pry ft. 505 ft 31 luP &Cril)l+e
Facility/Owner Name Facility ID#(if applicable) ft. ft __ r-
17111 Slab? Act'PS 11 ri Kerne(5vlJl�l 1C avatf ft ft F
Physical Address,City,and Zip ft. ft.
y. �,�r i nn
l or5 h 21.REMARKS �� V ` 3
'
County Parcel Identification No.(PIN) IFl:^•c;. < 1^:) ')r^.e:
. ..rt I.i r i
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: DV 's
(if well field,one Iat/long is sufficient) 22.Certification:
3C2° 4` 55 Cn" N u0° rg' 5/.5" W (II XQ 9104 1- '7.6.01
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 adcordance
7.Is this a repair to an existing well: Yes or No with 15A NCAC 02C.0100 or ISA 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 of this 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: 565 (IL) 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(§100')
construction to the following:
10.Static water level below top of casing: 50 (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: G (in.) 24b.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: 'lSE 40..7 QiC
(i.e.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) 61 Method of test:Coldi''1 A-IMP 24c.For Water Supply&Injection Wells: In addition to sending the form to
'I a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1Xfr1 /O Amount: t(ong. completion of well construction to the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016