GW1--05587_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD(GW-1) - Print roan
For Internal Use Only:
1.Well Contractor Information:
David Belcher ;
14.WATER ZONES G 1
Well Contractor Name FROM TO DESCRIPTION
4594-A 3cf0 ft• 338 ft. Id &s(Frapture�
NC Well Contractor Certification Number ft. ft. '
Aqua Drill,Inc. IS.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
FROM I TO I DIAMETER THICKNESS MATERIAL
Company Name 0 ft; 105 ft. G.a5 . In. I tg Chi ft 16.INNER CASING`OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: (96(pl FROM TO DIAMETER THICKNESS List all applicable well construction permits(i.e.UIC County,State,Variance.etc.) IL ft. in. MATERIAL
3.Well Use(check well use): ft_ ft. in.
Water Supply Well: 17.SCREEN - " '
Agricultural Ct al/PLLb1iC FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• F ft. ft. in.
Geothermal(Heating/Cooling Supply) z i Residential Water Supply(single)
IndustrialCornmercial ft• ft. in
Residential Water Supply(shared)
Irrigation 18.GROUT •
FROM TO MATERIAL* EMPLACEMENT METHOD&AMOUNT
I�
Non-Water Supply Well: 0 ft. j it -
�Ef1IO(itft? �,(;- Chr f�5"4' N�r3fre
Monitoring °Recovery
Injection Well: ft. ft
He
rate
Recharge °Groundwater Remediation ft. ft V
-
Aquifer Storage and RecoveryISalinity Barrier 19.SAND/GRAVEL PACK(if applicable) -
FROM TO MATERIAL EMPLACEMEN•TMETHOD
Aquifer Test IOStormwater Drainage ft. ft.
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) (©ITracer 20.DRILLING',LOG(attach additioaai'sheets if necessary) '0
FROM TO DESCRIPTION
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) IPTION(color,6ardnesa eoillrack ties grata size,etc.)
d ft. a0 ft. rLl
4.Date Well(s)Completed: g•114.2? Well ID# , ft. can rL
5a.Well Location: 66 ft. 140 ft. i Sandy �'1
SarOy co't
klichnleAs l.jriphF 100 ft' le) ft' lbw C-tcanr(
f.
Facility/Owner Name 4 FacilitylD#(if applicable)
105 ft. (105 rt. lit C-n-nq�lE
o7S'a -o pnc-f Church (Rd, JR{ebai ;ilk: (MOP "' ft. . es.....,....
Physical Address,City,and Zip ft. ft, N.yam gg� QQP-�q g.� )
r11.5i111e1 l 21:REMARKS ;. a
County Parcel Identification No.(PIN) A U G 2 5 Z Z 3
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: !_ , t t
Orwell field,one laat/long is sufficient) se�::..W.:�, r "'; �:P. .4'
t7 r n t 22.Certification: DWQ/•SOG
act: I�i �?.6 N �° 19_�.5't W ,,,,a '' to
6.Is(are)the wells) Permanent or Temporary Signature ofcenised eu Contractor Date
y signing this form,I hereby
7.Is this a.repair to an existing well: OYes or No l(s)was(were)constructed in accordance
w tifj,that 1ith ISA NCAC 02C.OIOt)or ISA NCAC 02C.0200 lV 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#2I 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 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: . uC .? (ft) 24a.For All Wells: Submit this form within 30 days
For multiple wells list all depths Ifd fferent(example-3ta200'and 2Qa 100') of completion of well
construction to the following:
10.Static water level below top of casing: MO ft.
If water level is above casing,use"+" ( ) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center;Raleigh,NC 27699-1617
1L Borehole diameter: Co (in.) 24b.For Inflection Wells: In addition to sending the form to the address in 24a
12.Well construction method: t aC i(' above,also submit one copy of this form within 30 days of completion of well.
(ie.auger,rotary,cable,direct push,etc.) 0Q construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Undergroiaad Injection Control Program,
1636 Mail Service Centex,Raleigh,NC 27699-1636
13a.Yield(gpm) 10 Method of test: (tom c\-T;Mp 24c.For Water Supply&Injection Welis: In addition to sending the form to
13b.Disinfectiontype: d the address(es) above, also submit one'copy of this form within 30 days of
'Y14 7O /C1 Amount: ICp(97 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