GW1--05926_Well Construction - GW1_20230918

4 I Print Form
WELL CONSTRUCTION RECORD(GW=flD For Internal Use Only:
...
1.Well Contractor Information:
David Belcher
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A R10 rt a I4 't' ,20 t^ M (Cror4u('e)
ft. ft. 1
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(If ap ileable)
Aqua Drill,Inc. FROM . TO DIAMETER THICKNESS MATERIAL
Company Name 0 rt. CC.g5 in. SVarill INC .
/� n/� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#:i^l4III eQ '007 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
FROM TO DIAMETER SLOT SIZE TnICKNESS MA�L
Agricultural °,, .�'cipal/Public ft. ft. in. '
Geothermal(Healing/Cooling Supply) Lii'Residential Water Supply(single) et ft. in.
Industrial/Commercial °Residential Water Supply(shared) I@.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft „9a ft t fl+Oniii.e P c 0,1)5 ci' liarait
Monitoring °Recovery ft. ft a
Injection Well:
R'Aquifer Recharge °G rotmdwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °. Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test °Stormwater Drainage ft. It
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION Dolor,hardness,soil/rack type,Brain size eta)
a ft. , 0 ft. Oa
4.Date Well(s)Completed: 9.11•,03 Well ID# c Q R' 7.5 ft 0 S Yndo SQiI
5a.Well Location: �� ft' V$, ft 1bl _I,t e
(la/o on Mnbl1P Nrlmes ncctceens,oro ft. ft. %945 Vie �xcrefl•Ite
Facili wner Name Facility MD((iffapplicable) ft. ft. E.� I' .o e,f ;"?�
579 i,ofile 'r)) Meid;5on 1 NC r�I^lt0PX5 it, ft
Physical Address,City,and Zip ft. ft. S E F 1 8 Z t)Z.3
tor,16:n hr�2M 79311�3(o4c96W 21REIYfARKS
/
County PamclIdentificationNo.(PIN) IRiJlr�.3:C7 Nl:.'=P•:+'ng Li Ili
Ca
Sb.Latitude anti longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certitica'on:
n
3(66,r1 0' LI,.R" N ` 9 54' cl(),Q" W Pas - _ 4-1 a?-83
6.Is(are)the wells) rmanent or °Temporary Signature of Certified Well Contractor Date
By signing this forte,I hereby certl�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 known well construction information and explain the nature of the copy of this recani has been provided to the Well owner.
repair under#21 remarks section or on die bark 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: c94 J5 (re) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and 2@I00') construction to the following.
10.Static water level below top of casing:. 40 (ft.) Division of Water Resources,Information Processing Unit, .1
If water level is above casing,use+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: CD (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
(�G A. above,also submit one copy of this form within 30 days of completion of well.
12.Well construction method: itt r construction to the following j
(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
13a.Yield(gpm) (20 Method of test: Cdk(ln C-[IMP 24e.For Water Snooty&Infection Wells: In addition to sending the form to
�t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type:I'� i©°/D Amount: i'Goc. 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 I Revised 2-22-2016
i