GW1--06674_Well Construction - GW1_20231017

1
WE CONSTRUCTION RECORD OW_g Print Form
For Intemai Use Only:
1.W Contractor Information:
Da id Belcher
Well mractor Name 14.WATER ZONES i
FROM TO 'DESCRIPTION
459 t913 191 >z' 89 GlPM (Frercittre)
NC Well Contractor Certification Number A/Oft' . atiS tt 'g&.i) (Frr(r4uce'
Aqcompu Drill,Inc. IS.OUTER CASING(for mulI.caredwe000R LINER(if a &able)
FROM TO ` DIAMETER THICKNESS TV(
yName • Q ft I 17r7 ft ! 6.955L I nRai !'V(
2.w. Construction Permit#: �:I•ll�`� U`7-41� 16o INNER CASING OR TUBING(geothermal cosed-loon)
List all llcable we11 eonstrrtotwn permits(LA C;Count',State,YariwweM f - DIAMETER THICKNESS MATERIAL
e ft.
ft.
!m
3.Wel Use(check well use): ft . fw ; io.
Water Supply Well: 17.SCREEN
°Allri ulturai IL"� ipaUPublia FROM To DIAMETERsLOTstzE THICKNESS MATERIAL
°Geo i ermal(feating/Coolin Supply) !"I Residential Water Supplyrt in.
g PP Y) � (single) ff. ft. In.
DInd Commercial DResidential Water Supply(shared)
i_:don - 1@GROUT .
• hr
Non ater 6u ' FROM TO MATERIAL. EMPLACEMENT MCLEOD&AMOUNT Supply Well: IL
DMon 'ring DReeovery O ft. ft• kxr; e Pdur l�hips`tt~1�1/d r e
Igie y ,n Well: O
it.
illA4u `• Recharge DGmundwaterRemediationilli
' r Storage and Recovery Salinity Beerier 19.SAND/GRAVEL PACK( ttonlleable)
�'AQ Test p� FROM TO MATERIAL EMPLACEMENT METHOD
Il..f S�za?waterDrRinage f. 1t:
•- ,,,..tal Technology °Subsidence Control ' ft. ft. I
'•..eeenal(Closed Loop)
>f
7lracer 20.DRILLING LOG(attach additional Sheets Mummy)
A -. 'ennal :-.•_Coolin_Return) *Other(4:.lainunder el Remarks FROM TO DESCRIPTION(cat or.tiEdcess,soll/rerk type.grain size.Na)
ft. RD
abate ell(s)Completea: l0�Co Well a�Q R. �(� ` Cie
!�` cjrtn
5a.W= •
i Location:
r9t Si�l i
6b va fe• Get 5rtny Cnil
Aria 146 >✓Prn(1)1}e, 74 R' , 97 -f` e8il e i-nl-.pplfile
Facicliityr/•. .erName Facility IN(ifapplleable) fr* ft:
rf�J C•tl6jPr,t1 Cie); � afe.`7 ,�iup tx(' :t�-• = .�. �. ..,_ ._
�-eCOUP C �trcll ' l ArtrItS�(11.MC ft. ;� ; -Physical .•.: City,and Zip •
[t. ft. n T r �:
•a A 1 l ►e.u ` ILLo' goggtla zI.REMARt36 OCT f1 S �;1��
County fParceel Identification No.(PIN) !In`o,.. ._. is
5b.Lad de and longitude in d es/egre minutes/seconds or decimal degrees: L .D`'•`':13` G •
Of well ti•Id.one let/fongis sufficient)
CcC L.p 22.Certification:. ;•
�t.G,3' N V9 e1 5'r7' S9.S°' w
.62eisf2se,_ . i
6.lis(are the well(s)Permanent or ©ITemporary s;gmtum ofCertitied Well Contractor
Jr).10• 3
Date.
B7.1s this a repair to an existing well: ®Yes or No with IISSANCAthLC 02C.0/Oorm,I O or S NCAC 2C m&that the �O0�Well C Guar n Standards and ghat a
Phis is*pair.fill out known well edtlatruction tnfommtion`andexplaln the nature of the eopyofthfsreeonlhes been provided to the wellewner.
repairun er#2lremarhsso:donoranthebackofthisform.
.23.Site or
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells havingthe same You may diagram eth back of this wellonal geto detailvide s:
constru-.on,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attacch additionaallh age well N�details or well
drilled: pages if necessary.
SUBMITTAL 1A16TItt1C1ImNS i
9 Total all depth below bud surface: 4r14
For wells list all depths iftb ereu(ample-3@.200'and2p1009 go24e.For All Wells: Submit this form Within 30 days of completion of well •
construction to the following:
10.Sta• water level below top of casing: WO (ft) Division of Water Resources;Information Processing Unit,
rimier I- is above caring use+"
•
1617Maiil Service Center,Raleigh,NC 27699-1617
11.Bo le diameter: (a (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well nstracHon method: } Intl p A'�r above,also submit one copy of this foim'within 30 days of completion of well.
OA auger: .tary.cable,direct push,etc.) construction to the following:
FOR W-TER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 276994636
13a.Yid, (gum) 10 Method Mesh CIA(h*1;mo 24c.For Water Suooly&Injection Wells: In addition to sending the'form to
13b.D• action e• I((l{`9��(d Amou the addresses) above, also submit one copy of this form within 30 days of
Amount: I(oo7. completion of well construction to the county health department of the county
where constructed. -
FonnGW North Carolina Department of Environmental Quality-Division of Wafer rm.,,,,,..m