GW1--07190_Well Construction - GW1_20231101

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Prirlt Form
WE L CO STRUC�.'I®RT REC:oiygD GW=fl . ,.... .. ._... .
For Internal Use Only:
I.W Il Contractor Information:
Da id Belcher
14..WATER ZONES , .
Well ntractorNemo FROM .TO DESCRIPTMON
45 -A Rib ' G O rt iv CAN (Track-um)
NC W II Contractor Ce►tificationNumber ft.. ft. I
Aqu gill,Inc. IS.OUTER CASING(formultkasedwells)ORLINER(Ifan limble)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name ft® EL 6..96 . in. %A m 11C
y 16 INNER C ORTUBING(isothermal cloaed400p).....
2.Well Construetion Permit#: 5�j(AQ ii}r.,Lj 5 FROM TO DIAMETER. THICKNESS MATERIAL
List all opplicable.well constriction permits(l e.UIC,.County,State,Variance,eta) ft: R. i In.
3.Well Use(check well use): fr. ft In.
Water Supply Well: 17.SCREEN.
Agtfcaitural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
IN•°(Imicipal/Publio ft. ft. in. ,
Geothermal(Heating/Cooling Supply) tr.,'Residential Water Supply(single) ft it In.
Ind :,'al/Commercial DResidential Water Supply(shared)
lirl..:ion 16.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non- ater Supply Well: ft'Mo toning Recovery 0 egO S�11�crit';4e Pelur ell:ps.df-Nytirs�)•P
ft ft
Igleeti n Well:
Aqui " Recharge DGroundwaterRemediation ft ft
Aqui( ;Storage and Recovery pSalinityHearier 19.SAND/GRAVEL PACK(ifapoticeble)
FROM TO MATERIAL.' . EMPLACEMENT METHOD
Aqui z r Test DStormwater Drainage ft ft. '
Exp•'mental Technology OSubsidence Control ft. ft
Geo. enml`(Closed Loop) OT(acer 20.DRILLING LOG(othadt additional dumb OnacesBaty)
Geo ettnal(Sating/coolingitetam)_ Other(expleinunder#21Remarks) FROM To DESCRIPTION(cour.bardnese,eoWisektor.'veiadae,ale•)
Q it. !o ft. C iQ
4.Date Well(s)Completed: IQ. tI,i25 Well ID# f?® ft• ,aj() ft- en srele)y 50;t
5a.W i Location: 30 f 66 ft (,i Ai• Brit col
J . ekes rL. :Oec Li< , 45 f'. 70 ` luP Cart 4P.
Facility/0 nerNeme Facility IDA(ifapplicable)
7Q. D• aliet IFLst? 6CrZt)i
$tO '4 Ai ,111E-62d/ qtratiNtem1 nbc Oaf/ e. rt.
Physical ddress.City,and Zip
Ala f•',ncn
21.REMARKS I, VI—4-f7 t o ii I;! a-_
County Parcel Identification No.,(PIN) N O V n 2
Sb.La 1 tude and longitude - �Oc3
ngl degreea/minutec/secoads or decJulaY degrees:
(ifwelif-Id,one fat/tongis sufficient)
2,2.Garb leatio : 111 s r r r'r r s J!✓r m
&c° i.t r a .i�, N 790' 19' 0a..7" �y �.`rD w,t t�G
6.Is(or) the wel(s) ermanent or EITemporary le,4----- te �?'•ca?Signaturd ofCll Contractor Date
By signing this fora,1 hereby are.that the well(s)was(wets)constructed in accordance
7.Is thi a repair to an existing well: °Yes or )! No with ISA NCAC 02C.0100 or!SA NCAC 02C.0200 Well Construction Standards and that a
f this is,rep60110u,latown well construction Information and explain the nature of the copy oflhis necmdhas been reared to the well owner
repair en'er#2l remarks section or on the hack of this foram. :
23.Site dfagraut or additional well details:
S.For reoprobe/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
constrll on,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
fiERGII1ST1r.A 1.tNSTnverIONs ! _. ,.. ...
9 Total ell depth below land surface: ,91.1.5
For mald•le wells list all depths pd(areni(example-3(d200y and 2®/00) ( ) 24e•For All'Wells: Submit this Earn within 30 days of completion of well
t onstmctfonto;the following:
10.Stall water level below top of easing: 40 (ft.) Division of Water Resources,Prater, el is above casing use KO Information Processing Unit,
1617 Mail Service Center,Meth,NC 27699-1617 •
1L Rowe ole:diameter: Co (thy
24b.For Infection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this}}'foray within 30 days of completion of well'
12.Well construction method: l t-tor/ Al r ,
(i e.auger rotary,cable,direct push,etc.) conattuetionto the following
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Progrram,
1636 Mali Service Coker,Raleigh,NC 27699-1636' -
13a.Yield(gpm) ITT Method of tee (r:•kin 4-11 vie '24e.For Water Sunni*&dnfectien Wells: In addition to sending the'form to
6�. the address(es) above, also submit;one copy of this fbnm within' 30 days of
13b.Disinfection type: I Ili, `it) e Amounts 16o0Z completion of well construction to the;county health department of the county
where constructed.
Form OW-1
North Carolina Department of Environmental Quality-Division of Water Resources ; Revised 2.22ill f: