GW1--07762_Well Construction - GW1_20231201

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WELL CONSTRUCTION RECORD(GW-I) Print Form -
For Internal Use Only:
1.Well Contractor Information:
David Belcher
14.WATER ZONES •
Well Contractor Name FROM TO DESCRIPTION
4594-A 380 fL 7V ,c ri CePE (Frarfu;e)
NC Well Contractor Certification Number ft. rt.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wens OR LINER(Ifap 'feeble)
FROM TO DIAME'rElt THICKNESS MATERIAL
Company Name �i ft. /�5 ft. �- c,1 in. .51�R(a), I 1k(-
2.Well Construction Permit#: E,N�SPY " (j, u 16.INNER CASING OR TUBING(lthermal closed-loop_
r )y FROM TO DIAME^.'EIt THICKNESS MATERIAL
List all applicable well construction permitr(i.e.WC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. t1, —' in
Water Supply Well: 17.SCREEN
Agricultural icipaUPublic PROM TO DIAMETEP_ SLOT SIZE THICKNESS MATERIAL
ft ft. hi.
Geothermal(Heating/Cooling Supply) 'dential Water Supply(single)
Industrial/Commercial R' In.
Residential Water Supply(shared) It(RtOIIT'
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well:
Monitoring QRecovery I ft' �i {ci11 rtli" hips 1' C�
Injection Well: B' OQ
Aquifer Recharge DGroundwater Remediation ft. rt.
Aquifer Storage and Recovery Salinity Harrier 19: VEL PACK BfanDUcable)
FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage it. R.
Experimental Technology Subsidence Control f(, B.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach addtdonu sheets tf ss cessary)
Geothermal(Heating/Cooling Realm) Other(explain under#21 Reredos) FROM TO DESCRIPTION(Mar,Pardons,soWroek type,arata.ae,sx)
O R. 0/0 &
4.Date Well(s)Completed: I I', ,7'2 Well Mt 2CD tt. 50 a. (Dr.
Sa.Well Location: 50 ft, .6 g, ,A 20
i;'(PO 11S dial ft.
Faciliry/OwnerNetrte 'S5 `'�� �i(yf_�r('ctnil•r'
Facility ID#(if applicable) it ft.
t13(1 (trier i it -tJ art `I'e;r.jSU;lh , vUL oa73, a rt. tr.
Physicalhy Address,City,and Zip g, it. —
Y1CICK:c'1 )1 .01 21.RISIIIARit6
County Parcel Identification No.(PIN) _
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
22.Certilleatlon:
3(r° .2/' 16.(c" N '7`-` 5y t 57, S'„ w ^n
6.Is(are)the well(1)(Permanent or JTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: O 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 in ormation and explain the nature of the COp}of this record has been provided to the well owner.
repair under#21 remarks section or on the back 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 I GW-i 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:
For multiple wells list all depths((different(example-3(Q200and 2®I00) ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: C C (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 fin.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: �f4(1$ A.: above,also submit one copy of this faun within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mall Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ri• !Flatbed of test: (f►4 "V'flow24e.For Water Surely&Infection Wells: In addition to sending the form to
1t the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTI{'7 /S Amount: 1(d.0L 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 2-22-2016