GW1--05577_Well Construction - GW1_20230825

v.
WELL CONSTRUCTION RECORD(GW 1 print Form,
For Internal Use Only.
1.Well Contractor Information: I
David Belcher
14.WATER ZONES t
Well Contractor Name FROM TO DESCRIPTION
4594-A a6bft. 4),2CcSrt «.( /Jj ()cnrkure)
NC Well Contractor Certification Number ft. ft.
Aqua Drill, Inc. OUTER CASING(for maltl-cased wells)OR LINER(if ap licabte),
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 IGil ft. I G.06 in. I PPa► 'I've
16:INNER'CASING OR TUBING(geothermal dosed-loop)'2.Well Construction Permit#: tS Lv f?-Qp(')17). c9n 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
DAgricultuml ©I icipal/Public FROM TO DIAMETER '' SLOT SIZE THICKNESS MATERIAL •
ft. ft. in-
0 Geothermal(Heating/Cooling Supply) at!Residential Water Supply(single)
ft. ft. in.
Dlndustrial/Commercial
DIResidential Water Supply(shared)
Irrigation 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well: [t ft /2__'- 'Peter
Monitoring Recovery [t a1 jni�e Y/7ur (hips�I'N/e1(
Injection Well: ft.
Aquifer Recharge Groundwater Remediation h• it
Aquifer Storage and Recovery Salinity Barrier
19.SAND/GRAVEL PACK{if applicable) '
FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test I�Recoveater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) I°Tracer 20 DRILLING (attach additianal'stieets ifneeess
GeothermalFROM DESCRIPTION(color,hardness,soluracit
(Heating/Cooling Return) Other(explain under#21 Remarks) ft. TO 10 tG type,grain sire,etc.)
4.Date Well(s)Completed: g•i0•(19.8 Well IN 10 ft. 94 ft. /! %i`
I(; 1rle
5a.Well Location: 611 ft. q VI
nI ft Swe ' (tf!!Me
Armin C 11ins R. ft.
Facility/Owner Name nn /� t Faciiity1D#(if applicable) ft ft.
f�O�)CsiS(M Y1U SP.Plt7frx Arc e
Ll� I Er wn ft. rt AUG �+
Physical Address,City,and Zip I I UG 2 e5 L G L 3 •
�ecson A alb'• / 21.REitfARKS , --
IftiGitT CI i',::::ac.r4 Ur.-
County b
� a+u� -
Parcel Identification No.(PIN) TWARI .,Oris
5b.Latitude and longitude in degree s/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient)
g� 22.Certification:
Xo d.n. c21.I II N 79 d is 1.Q n W L.f:If TC Y.caivi, a
6.Is(are)the well(s) Permanent or Temporary Date
te
Signature ofCertified Welt Contractor '1�•�3
By signing this form,i hereby cenlfy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or No wish iSA NCAC 02C.0100 or I5A 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°PPhis 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 to 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: _O5 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 f/200•and 2(a3100� y p
'construction to the following. I
10.Static water level below top of casing: 140 (R,
Ifwater level is above casi ) Division of Water Resources,Information Processing Unit,
ng trse +- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (90 (in.)
(� 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Amy A',p above,also submit one copy of this within 30 days of completion of well.
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
•
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Method of test; (n?rCh 'V Time. 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: 14111 NZ% Amount: tGonz. 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