GW1--06672_Well Construction - GW1_20231017

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", I Print Form-WELL CONSTRUCTION RECORD(GW4 For Internal Use Only: l
1.WI l Contractor Information:
Dailid Belcher
14.WATER ZONES. I •
Well Contractor Name FROM TO DESCRIPTION
4514-A AO e. 0/91 [t SCAIll (1rrfr-i!(Ce)
NCVU'I1 Contractor Certification Number ft. ft.
Aq a Drill, Inc. is.OUTER CASING(for muttkased wells)OR LINER(If ap linable).
FROM TO I DIAMETER TItEEC(R�NESS MATERIAL/� i
Comp nyName l I [t I 175 ft. 1 G.g5 in. I SDRc2I ("VC
A^n 16.INNER CASING OR TUBING(geothermal closed=loop)' I
2.W I Construction Permit#:. 34k)t", 11-(NS FROM TO DIAMETER THICKNESS MATERIAL i
List al applicable mil construction pennies(Le.UIC,County,State.Variance,etc.) ft. ft In.
3.W Use(check well use): it ft. in.
Wate Supply Well: 17.SCREEN
OA cultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
unicipal/Public ft. [t in.
OG elmel(Heating/Cooling Supply) (.i Residential Water Supply(single) .
Ind trial/Commercial rt [k In.
�Itegideatial Water Supply(shared) iS.GROUT i
IlIrri lion ;
FROM,.:,- TO ' MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well: i
1Morlitoring DRecovety .O f4 rt,. "l n�i� (r C�1��S HI( �p
Injection Well: (�-
DAquti(ferRecharge DGroundwaterRemediation it ft-
DAquifer Stotage apd Recoveay ®ISalinity Barrier 19 SAND/GRAVEL PACK(iif applicable)
FROM TO MATERIAL- EMPLACEMENT METHOD
°Aquifer Test DStomtwaterDiainage ft . ft.
DExpi rimental Technology DSubsidence Control ft g,
DGeothermallI (Closed Loop) (Tracer 20.DRILLING LOG(attach additional sheets if necessary):
f Geotlhennal(Reating/Cooltng Return) f Other(explain under#21 Remarks) FROM TO DESCRIPTION(color.hardness,wluiocktype.amid du,eta)
4.Doti Well(s)Completed: 9•`I•e23 Well w# 4..ft. 7Q ft. CIIY(�;'Sfp
Sa.W 11 Location: V g. 75 ft ' III Cyr i e
Tan Pr '7><Ai�+ Rows Lk(' ft3125 ft- i�ta 'ttrMilP
Facility wner Name Facility ID#(if applicable)
ft.R• [t
ig,j ThP.f ric 1itfwi L4)r1r / $#ry cegclrtte A,lr 45 . ft.
Physics Address,City,and Zip ! ft. ft.21.
REMARKS ;� a
WA3poq(o5'r71�j _:.. ..
County Parcel Identification No.(PIN) • O C T j 7 2023
•
5b.Latitude and longitude in degrees lminuteslsecontls or decimal degrees:
(ifwell eld,one taNlong is sufficient) l��` ;1._.:..:i : ;
22.Certiflcation: p,. =• .4-.,,,,,.,I err
° 9` toa" N � 5R� JI.o W :�
6.Is(a I)the wel(s) Permanent or Temporary Signnature�fed WeU—Contractor at a�
Date
By signing this fort,I hereby certify dial the well(s)was(were)constructed in accordance
7.Is thisa repair to an existing well: Yes or No with 15A NCAC 02C.0I00 or ISA NCAC 02C.0200 WeU Construction Standards and that a
Ifthis is b repair,JIll out known well construction information and explain the nature of the eon'ofthis record has(eeriProvided to'hewn owner-
repair udder#21 remarks section oren the back ofthis Ann.
23.Site diagram or additional well�detals:%.
8.For Cseoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
constru don,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
,SUBMITTAL INSTRUCTIONS
9.T well depth below land surface: 5 (ft.) 24a.Far All Wells: Submit this form within 30 days of completion of well
For mul le wells list all depths(fdi$erent(example-3@200'and 2Q100)
construction to the following:
10.Sta c water level below top of casing: LJQ
(
Iftvater Ipvel is above casing use•+- (ft.) Division of Water Resources,Information Processing Unit,
1617 Mail.Service Center,Raleigh,NC 27699-1617 •
11.Borehole hole diameter: 6 (in.) ! '
/� ' 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method: lv�4Gp� ;r above,also submit one copy of this'form within 30 days of completion of well.
(Le.auget rotary,cable,direct push,eta) construction to the following:
FOR II,,TER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yi d(gpm) 3 Method of test: (a0C\`k'Y101,0 " 24a For Water Sumoly&Infection Wells: In addition to sending the form to
o , the address(es) above, also submit l one copy of this form within 30 days of
13b.Disinfection type: I-I `ri-I o/n Amount: I(nz completion of well construction to the county health department of the county
( where constructed.
Form I 1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016