GW1--05810_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD(GW y' F Print Form
or Internal Use Only:
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1.Well Contractor Information:
David Belcher I
Well Contractor lYeme 14.WATER ZONES
i FROM TO DESCRIPTION
4594-A 3qW 1t 4o0 it, 36PMiq ')
NC Well Contractor Certification Number rt. n.
Aqua Drill, Inc. IS.OUTER CASING(for multi-cased:wells)OR LINER(if an livable)
FROM TO DIAMETER THICKNESS MATERIAL Name a 1ffi I �1$' ff I (a.o'!5 in, I Sl9al t'
Z.Well Canattvction Permit#eft)(OcZ3(�,rj•('j 1 16.INNER CASING OR TUBING(geothermal closedleop)
FROM TO DIAMETER THICKNESS MATERIAL
Listed!applicable wellwnstraction permits(i.e.WC County,State,Variance,etc.) ft. ft. In.
3.Well Use(cheek well use):
ft ft " in.
17.SCREEN
water.Supply Well:
ttt��q
Agricultural tmicipa11Pablia FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. it. la.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
Industrial/CommercialR• ft. in.
Residential Water Supply(shared)
Irrigation 18.GROUT '
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT MErROD&AMOUNT
°Recovery I Q ft r n ft �,�e Pour Ch,�s 4H��lrr
.MonitoringO(
Injection Well: ft. it
Aquifer Recharge °GroundwaterRemediation it ft.
golfer Storage and Recovery OISetinity Barrier ( 19 SAND/GRAVEL PACK Of smokable)
Aquifer Test f,�, FROM TO MATERIAL EMPLACEMENT METHOD
�IStonnwaterDrainage) ft ff.
Experimental Technology °Subsidence Control ft ft.
Geothermal(Closed Loop) ®ITracer 20.DRILLING LOG(attach additional sheets if necessary).
Geothermal(Heating/Cooling Return) Other(explain.under#21 Remarks) FROM TO DESCRIPTION(color,hardness.salYrotk type.Bruin she.etc)
6 ft. ..9() ft' Cla
4.Date Well(s)Completed: f{•30•S13 Well ID#
Sa.Well Location: 0 le. `73 f t let d ,� ;I
rFS Crilq nte4.i0n -Itv { Vie tt. 145 I0 GcmnAe
Facility/Owner Name FacilityID#(ifapplicible) ft• ft.
1124 1,.ad.I)conuiIIP Avenue.,nt1 e AI e;46u►lt Orli 3010 ft. {ft. I ' A u Li
Physical Address,City,and Zip / C �� � �>" ��6
t`ed'K(IIC�hQI)1 •
$9151�an5Lig 21.REMARKS SR i 2 7.023
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrees/minutes/seconds or decimal riegrees: 109 e `tl I?'-; :� v f,y is i :
(if well field,one lat/long is sufficient) C'�}°i+;' ,
22.Ceetifivation:�,o
W Tfi/r/q.
6.Is(are)the well(s)Permanent or [ Temporary Signature of Certified Well Contractor Date •31 a3
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 e
Ifthis Is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the ivell owner.
repair under#21 remarks section or on the back of this fonn. 1
i 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 I 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: LIPS I (ft.) 24a.For All Wells: Submit this forrm,within 30 days of completion of well
For multiple wells list all depths fd fferent(example-3@200'and 2(g1009 '
construction to the following: ,
10.Static water level below top of casing: I-IO (ft.) Division off Water Resou Is,Information ProcessingUnit,
If water level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617 •
11.Borehole diameter: CO (in.) 24b.For Infection Wells: In addition t9 sending the form to the address in 24a
m�`u,,�ye A' above,also submit one copy of this form within 30 days of completion of well.
12.Well construction method: �r�
(Le.auger,rotary,cable,direct push,etc.) /! ` construction to the following: i 1
FOR WATER SUPPLY WELLS ONLY: V , Division off Water Resources,Underground Injection Control Program,
I 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: I
�'�YMp 24c.For Water Supply Sc Infection 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: UM�7O°�4 Amount: /Cgpy completion of well construction to the county health department of the county
# where constructed. I
Forn GW-I - North Carolina D cpartmcnt of Environments!Quality-DIvision of Water Resources Revised 2-22-2016