GW1--04848_Well Construction - GW1_20230728

v Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
David Belcher 14.WATER ZONES ,
Well Contractor Name FROM TO DESCRIPTION
4594-A 36 0 ft. 3(a& ft. 3(„MI
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIALt
O ft. "s' ft. Ce. 15 In. a I t'Tvc
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop) •
2.Well Construction Permit#: rQ 297 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(Le.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
DAgricultutal tmicipal/Public ft. ft. in.
0Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt, g, in.
Qlndustrial/Commercial DResidential Water Supply(shared) . 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: () d- a3 ft iirm-on.,4e %AC ()(1T 4-ul kvke
Monitoring ORecovery ft. ft.
Injection Well: ft. ft `
QAquiferRecharge [iGroundwaterRemediation 19.SAND/GRAVEL PACK(ifapplicable)
QAquifer Storage and Recovery IDSaiinity Bather FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage ft. ft
Experimental Technology Subsidence Contiol ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,sell/rack type,grain she,eta)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) O ft.
ti? ft (`a
4.Date Well(s)Completed: '7• I 3.'(9I Well ID# t,70 ft. 30 ft ) S'irlcP £o
5a.Well Location: 30 ft. 73 "ft Snit
V' i rh (A)1,1 73 ft. %c' ft rue rxcan 4
Facility/Owner Name FacilityID#(if applicable) ft, ft t ,
�r7]r�ty'� nn �1 R.t PP ) �s� 3F�s �Ilae �•f(�nl�
,QSY0 cr05 PCk Church ,c�, MebalrlP. 'UC ft. ft r... �*n' ��++ P .
A'"-W u � S...1 t.7
Physical Address,City,and Zip / ft. ft. V\;�'Le C_,ii 'f ar"'
( r,swei1 21.REMARKS fi JL �. 0 e fl uU3
• County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: n&e,r•P
Orwell field,one lat/long is sufficient) 22.Certiticatlo : [XtrK,Ii
3G° 16' 5.0" N '79° 1`7' 30.g't W .¢k 9-a5-a.3
6.Is(are)the well(s)Permanent or Temporary Signature offer 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: Yes or No with 1SANCAC 02C.0100 or ISANCAC 02C.0200 Well Consnucton Standards and Brat 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 ivell 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 toy provide additional well site details or well
• 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: 3%5 (ft.) 24a.For All Wells: Submit this form within 30-days of completion of well
For multiple wells list all depths Ifd fferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: LI 0 (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: t!9 (in.) 24b.For Iniection 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: gokot/ kits onstruction 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) 3 Method of test: alkf.k1 11 ole 24c.For Water Supply&Infection Wells: In addition to sending the form to
G the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: �1� 70 /0 Amount: I(aoZ 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