GW1--05590_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD(GW g) PrantForm;.
For Internal Use Only: i ���
1.Well Contractor Information:
David Belcher
14.WATER ZONES 1'.4
Well Contractor Name 1FROM - TO DESCRIPTION
4594-A a ft e9g9 f t. 5 Oil(Mae-ore)
NC Well Contractor Certification Number „300ft' 5 rA ft' )5&PM lThtt ,,rP)
Aqua Drill, Inc. ''15.OUTER CASING'(for multlrgsed:wegs)'OR'LINER(if an°Ileable). -
._; •
FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 fL I 90 ft I a5' In. I TAM 4)/c
'.16.INNER CASING;°RTUBING(geothermal closeddoop).• .•.'.._-
2.Well Construction Permit#: a07 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) -. ft. ft ill.
3.Well Use(check well use): ft ft , in.
Water Supply Well: 17!SCRIM
-AgriCnitural- FROM - TO DIAMETER SLOT SIZE THICKNESS MATERIAL
unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single)
ft ft in.
Industrial/Commercial OResidential Water Supply(shared)
1&GROUT
Irrigation
FROM TO MATERIAL EMPLACEMENr METHOD.&AMOUNT
Non-Water Supply Well: ft �4 1
Monitoring [jRecovery - .ft. ft ft �Pnlr)ni�e Yr`Ilf� owl �1 i �fGt[P
Injection Well: •
(/
quifer Recharge OGroundwater Remediation R. ft.
Aquifer Storage and Recovery 19.SAND/GRAVEL PACK(ifappncable).. • •_ `' -
EISalinity Barrier FROM TO
Aquifer Test j�StotmwaterDrainage ft ft MATERIAL I EnfPLACEMENTMereon:
Experimental Technology OSubsidence Control ft. ft
Geothermal(Closed Loop) °Tracer
- ZD:DRILLING LOG(attach addrhonal'sbeets if necessary) '=";`�
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness.soil/rock type,Mrain Bin.etc.) ..
0 ft. o�D ft. Cla ,
4.Date Well(s)Completed: i'/5'03 Well JD# (90 it. u® ft. (Or 1
5 � $�i
Sa.Well Location: 110 ft a5 ft f l'$ r, / Se);) ,
/...UKC MQqers g5 ft. 90 ft flue '(traf�;E'e
. Facility/Owner Nang Facility ID#(if applicable)
90 ft 3a5f� 'flue C-rr�,In;+e
756g Uid9 6a A), $ranch,AlC i' r 1709
Physical Address,City,and Zip ft ft ;1 A. _ L.i V
t!LCSWe!( 21.REMARKS. 6� �}
County AUG Le 5'L023
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ,1,.c«.ar vn f rw c •t°.�tin.4
(if well field,one]aVlong is sufficient) 22.Certification: ( a LV 3vED
3C2° c791 i0.0r' N "9° our E7.S" W
t3
6.Is(are)the wells) Permanent or E3Teroporary Signature of 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: O Yes or No with 1SA NCAC 02C.0100 or ISA 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 been prodded to the well owner.
repair under#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
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: -
r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 125 (ft) 24a.For All Wells: Submit this forma within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2(2)100) construction to the following
10.Static water level below top of easing: UD (ft.) Division of Water Resources,Information Processing Unit,
If mvater level is above casing use"+ 1617 Mail Service Center;Raleigh,NC 27699-1617
I.
11.Borehole diameter: 6 am.) 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: ,(340('L/ Air construction to the following I'
(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
m /� t i
13a.Yield
(BP ) NO Method of test:ratCh—i- 11119. 24c.For Water Supply do Injecton Wells: In addition to sending the font to
NTH`��� the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: /O Amount: !COOL 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