GW1--07191_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD(G1�►=fl Print Form
For Internal Use Only:
1.W ll Contractor Information:
Da id Belcher .
Wall Mortar Name 14.WATER ZONES I
FROM I i0 DESCRDTr[ON
45914-A a e2 `. QLU r`. 4C tti (Freir-lure)
ftNCW iIContractorCertifcationNand= R'
Aqua Drill,Inc. Out CAsrNG Obr mnitkated walla)oR LINER(Ilia cable)
FROM TO DIAMETER THICKNESS MATERIAL
Compile)/ 0Name R' I Ga " I a,:,7 ' gI (P vC
Z.WeltContitrttctio®Permit#!: '75�lt )E L /LJ � 16.OM INNERCASINGORTUBIA�thermaledl000)
List all applicable well construction permits(le.UIC,•Cowtty,State,Variance,Plc. t, TO ft R in. THICKNESS MATERIAL
)
3.Well Use(check well use): R, n, iw
Water Supply Weil:
17.SCREEN
Agricultural aniCipal/Publia FROM TO DUMMER SLOT SIZE THICKNESS MATERIAL
Geothemtal(Heating/Cooling Supply) Supply( g ) ft. ft. in.
sidential Water S (single) ft. in.
Industrial/Commercial l
Residential Water Supply(shared) IS.GROUT Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 6 ft. 696ft.
Monitoring DRecoveryt°)l0 ��eOLPf`ohi�JSd� i]yCrlre
Injection Well: rr
Aquifer Recharge ri(iroundwaterRemediation
Aqui r Storage and Recovery �3aluuty Ranier FROM
OAND/tiRAVEL PACK fATEllerble)
FROM TO MATERIAL EMPLACEMENT METHOD
qui Test EIStonmwaterDrainage ft. • ft.
Expo Natal Technology DSubsidence Control • ft. ft. ,
G annul(Closed Leap) DTracer 20.DRILLING LOG(attach additional sheets Ifnecewary)Geo ennui(IfeatinglCooling Return) Other(explain under#21 Remarks) FROM TO DFRCRunIrON teaUr,aoeaaeu,eaIDmektyoasola eta)
ft TO
4.Date We l(s)Completed /®.A71. :A Well IN R ft. �J It' �49{y-
Sa.Well Location: a+
•
�j f G tllif� fl'Itt:
'TCo it et;.dlc)e m Li..I• ER ft' 5 n (r P.1(grr3.ckle
Facility/Owner Name Paelli loll lh:eble(if R.ty 0AA )
79 0 A) kw.aa, eivicivant me c77 1*7 R:. ft
---- • rJ r Li
PhyisicalAddrass,City,and tip fr. ft. I NOV 1 1 79 q
h�lalrlctstC'c m.REMARKS'
County
Parcel ldcaHflcatlon No.(PIN) Iflr� Y 7^t7 •,�,u':.,24.7•
.4-'i(..4'
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: 4�"��
Ofweli field,one lidless is sufficient)
22.C'ertitleatiot
6.Is(are)the wells)1 Permanent or ®Temporary !C9•°?�'°`�3
Signature of W ontiactor Date
7.Is this a repairO By signing this fbma,1 hereby care dud the we11(s)was(were)constructed in accordance
to an existing Yes or NN��tllf No with ISA NCAC 02C.Of00 or ISA NCAC 02C..020D Well Construction Standdnds and that a
Oils a repair,fill out known well construction bi/brmatlon and explain the nature of the Copy eihts racmahasbeen provided tolhe well owner.
repair under#2/remarks section ores the hack ofshis 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 pmvide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.drilled:
FrmmitTTAr.nvsratre menus
9.Total ell depth below land surface: A �j
Forman le weR+Ost all depths re/ rent(example- d2Qa 100) ( ') cons For All thefWens: Submit this form within 30 days of completion of well
construction to the foflowing: •
10.Stati water level below top of casing: d/p i
Yuutar 1 el is above casing,use (It) Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 276994617 •
11.Bore ale diameter: Co (Is)
24b.For Inieetton Walls: In addition;to sending the form to the address in 24a
12.Well natructlon methods 'ikp{ ry Al(' above,also submit one copy of thisffoim within 30 days of completion of we11•
(Le auger rotary,cable,direct push.etc) consbuction.to the&Halving:
FOR WATER SUPPLY WELLS ONLY: • Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
4
13a.Yield(gpm) , Method of test:fate Irl11�G� 24c.For Water Sunfly&Infection
t, walls: In addition to sending the'form to
13b.Disinfection type: 1.1114 9D°/o the addresses) above,also submit one copy of this form within 30 days of
(Amount: 1(..t�z completion of well construction to the'county health department of the county
•
where constructed.
Form OW-1 North Carolina Depart tent of Environmental Quality-Division of Water Resources i
Revised 2.22-2016