GW1--04720_Well Construction - GW1_20230721

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
Print Form
1.Well Contractor Information: 1
David Belcher 14.WATERZONES I
Well Contractor Name FROM TO DESCRIPTION I \\
4594-A .g(0.6% aG3 ft. )a CZ'QM (crpcA-tire)
ft. ft.
NC Well Contractor Certification Number
IS.OUTER CASING(for multi-cased wells)OR LINER(if ap cable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL/ /
Company Name Q ft. 39 ft. Ca n` In. 5%91
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: 3 U.5 5a FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coney,State,Variance,etc.) ft. ft. In.
•
3.Well Use(check well use): it ft in.
Water Supply Well: 11.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ° cipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Wesidential 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: ° ry 0 Ift. 93 ftt. fieMo e (Pour Chips 4 H100PrkIe
Monitoring Recove
Injection Well:
Aquifer Rechargeft. ft.
°Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable).
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ,°Stormwater Drainage ft 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(color,hardness soiUrock type,stain size etc.)
0 ft' cg ft C_1u
4.Date Well(s)Completed: 7 10•gs Well ID# fi ft. 3q ft. CX 81
rit
Su.Well Location: gq ft. d ft INC ,Mike
Sn1onn ahrlekovI� it. ft. D s r. -"a •.
Facircilli�ity/OO�wnerName /� Facility ID#(if applicable) ft. ft. B A L#[1 Vt f)
..,2 Lk$l 1c)eon lAr)s,City,and 1 f-rsees l:llel AJC g7r9g'q ft. ft.
JUL .1 1 2023
Phy21.REMARKS k' nn Pry^!` yr
OP1441 fogq7178'7 t`1 '�-:� ti;;'
County Parcel Identification No.(PIN) e4t "T+VMl
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: -
(if well field,one tat/long is sufficient) 22.Certification:
3( ° q' aQ3.sir N co° 1' 1-11.3 W
TottXiC 11-- 7•t1•,23
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: °Yes or NO with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standen ds and that a
If this is a repair,fill on:1mown well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider#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
S.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: gir6 (f) 24a.For All Wells: Submit this form within 30 days of'completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2Q100') construction to the following.
10.Static water level below top of casing: ut0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (o (in.) 246.For Infection Wells: In addition to sending the form to the address in 24a
�f above,also submit one copy of this form within 30 days of completion of well-
12.Well construction method: .t1O{rtt ,i' construction to the followin
(i.e.auger,rotary,cable,direct push,etc.) g
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 2 769 9-1 63 6
13a.Yield(gpm) la Method of test: Cri1/411 +-t ytg 24c.For Water Supply&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: 14714'709/0 Amount: 160Z. 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