GW1--05588_Well Construction - GW1_20230825

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
Pnnt''r orm
1.Well Contractor Information:
David Belcher •
14.WATER ZONES 1.
Well Contractor Name FROM TO DESCRIPTION
4594-A 53d11' 5M ft' ? CAM ( eaCdtttP)\
NC Well Contractor Certification Number 5 o O" 5g6' a3(-6I+F( (jsn d'(,tre,l
IS.OUTER CASING.(for multl-cased.wells)OR LINER(Wan linable)'
Aqua Drill, Inc. FROM TO DIAMETER' THICKNESS MATERIAL
Company Name 0 ft 50 ft 645 ln. 5IAGiI (PVC
16.INNER CASING OR TUBING(geothermal closed-loop) 'l'
2.Well Construction Permit#: 1917 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft ln.
3.Well Use(check well use): ft ft in.
Water Supply Well: 17.SCREEN
DDAgricultural cultural � FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
E9 unicipal/Public ft. R. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
°Industrial/Commercial °Residential Water Supply(shared)
a�, 18.GROUT
yI1T1(ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft ft. /,�
Monitoring °Recovery ft. �� ft itZd�nife I't1 air Chi ,g "� HC{�(C(fP.
Injection Well: -
Aft.ft. ft
q Recharge DGroundwaterRemediation
Aquifer Storage and Recovery Saliri Barrier 19.SAND/GRAVEL PACK(if applicable) - ,
FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Test ©iStomrnaterDrainage ft. ft.
°Experimental Technology °Subsidence Control ft. ft.
°Geothermal(Closed Loop) I°Tracer 20.DRILLING LOG.(attach additional sheets ifnecessary) --
°Geothermal(Heating/Cooling Return) I°Other(explainunder#21 Remarks) FROM TO DESCRIPTION(color,hardness soiyruektype grabs size,eta)
0 ft 10 ft Cla ! '
4.Date Well(s)Completed: S-11;'•a3 Well ID# 010
ft. u5 ft 0 ' _ i c i ,
5a.Well Location: ((5r ft 50 ft n IX3/c�Di(P. (�,u , e
Q�
(-rerrnk) (c�trcelrr) do ft' (45 f. % ie. (tra�ni4e
Facility/Owner Name Facility ID#(if applicable) ft. ft.
,iq e. (Dr 3 Prt)v;dt'nc,, MC n97315 ft. ft. ,rw .r..e
Physical Address,City,and Zip ft. ft. L Lz I V'E
21..REMARRS A
County f AUG 5'2023
CO1mh Parcel IdcmiScation No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: "6f6---a+;.
(if well field,one lat/lon is "1 Pr -^.-r^ A��g sufficient) 22.Certification: cilsa^y a
36° o9' 57.5'r N 79C RI' 4G.1n W
_I .04rjasi------- i' R.S1-a3
6.Is(are)the wells): Permanent or Temporary Signature of Certified Wall 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 ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair.,fill out(mown well construction information and exptairt the nature of the copy of this record has been provided to the well aiwter
repair under#2I 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: (n a5 (ft-) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(1diffirent(example-3@200''and 4)100') construction to the following: 1 '
10.Static water level below top of casing: 40 (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 Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this fonn within 30 days of completion of well•12.Well construction method: [y. As r construction 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
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13a.Yield(gpm) So Method of test: Crtiren-1-1.,Inp 24c.For Water Supply&Injection Wells: In addition to sending the form to
0 the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: MNt7Q /) Amount: 1(pfi7 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