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WELL CONSTRUCTION RECORD(GW 11 For Internal Use Only:
• 1.Well Contractor Information:
David Belcher
1d.WATER ZONES I. ;
WellCoatractorName FROM TO DESCRIPTION
4594-A i60 ft' HA ft' ten C .M (1'ctAettg(e) _
NC Well Contractor Certification Number ft. s
Aqua Drill,Inc. IL OSIER CASING(for mmtkaeed walls)OR LINER MD 1lanbte)
FROM TO DIAMETER THICKNESS MATERIAL
Company Name i ..g5 R' I 646 im I s,�P. lC
2.WeIIConetnrct(onPermit#: �� .lw-INNER CASING OR TUBING me.lherm dill Waite) -
List all applicable vmieanstructlan pernats(l e.WC,Corny%State,Variance,eta) FROM DIAMETER THICKNESS MATEaL1L
ft. ft. ra.
3.Well Use(cheek well use): n ft. i in.
Water Supply Well: 17 SCREEN
Agricultural anicipaUPublio FROM. TO DIAMETER . SioTSIFE .THICKNESS MATERIAL '
Geothermal cati ft,. ft. in.
mg/Cool 1°€Supply)DP Y) Residential Water Supply(single) ft. t7, in. .
IndustriaVCommer,ial DResidentiel Water Supply(shared)
Irrigation iR Gam
Non-Water S FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
apply Well:
Monitoring ft'
3 f Re;?ic'rll� P lam,it rr ("I���s )a� ► 4�
�Recovtsy
cation Welk
Aquifer Recharge DGroundwaterRemediation
r Storage and Recovery D9alinity Barrier19.SAND/GRAVEL PACK(traunucablel
FROM. TO MATERIAL I EMPLACEMENT METHOD
*lifer Test illIStormwater Drainage R. ft. 1
Experimental Technology DSubsldence Control • ft. fr. 1:
Geothennat(Closed Loop) bTracer 2O.DRGLOG( SOfl .J if necessary)
Gcothermal(ggattog/CooliegRom) riOther(explain under#121Remarks) FROM TO oescluPriON(Wan itaaaecs,enWrackiMgreydxeopgL
4.Date Well(s)Completed:II.i`7.r� - . Wellm# f 1 'DPI
Sr/i Sc�:l
7
5a.Well Location: 85 R' /e5. (NIP! 6c LC rt
14npal.pc More) 1 CAI C mare ft. fL 77
Facilty/Owner Name 0 '
Facility Me(if applicable) • R. ft. " .4,r ;` s ti-W r
jt5� 'pr1 t3rrfrl N.rI i t1 ,. .,
e' l C �7n?uq. �' ft. D� ? .3
Physical 'Clty,And z(p , ft. ft. C -� Cu 3
Caswell 2i.REMARKS - .
Z., .ter .r,�
County ParoelIdendScatieallo.(PIi� i ' , � 7' •:d 1...Ira
Sb.Latitude and leagitude In degrees/minutef/sesends or decimal.degrees: •
(ifweli field,one ktllong k auffieienq
22..CeriiReation:
get° lrer ,c1Ca`', pl r° '7j 51(.8" W
6.Is(are)the well(s)0PPermrinent or DTemporary Signaturefq ,ed War Date
l• ��b`?• 5
Da
9.Is this aexisting By signing this form,I hereby certify that the svei(s)was(were)constructed in accordance
repair to en well: Elites or Iv,,No with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and drat a
;this isarepak jliiout
well cons rgglieuknow!well construction hiformtion and whin mattes of the CoPYofthis neemdMas been Provided to the wall owner.repair under 021 remarks section oraa the hackoftluis form.
23.Site diagram or additional well details:
8.For Geoprebe/DPT or Closed-Loop Geothermal Wells bavlug the same You may use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You Dray also attach additional pages if necessary.
drilled:
SURIVO TAI,.INSTRUCTIONS
9 Total well depth below tend surfaces I Slit •FornialtiplewellsAnalIdepths(fd(8erect(example.3(4200'and2®lOD9 (B') emu•for An Welds Submit this form within 30 days of completion of well
construction to the following: ; j
10.Static-Water level below top Of casing:
Ifwaterlevel is above casing,we"+" (ft.) Divider:oYWater.Resotu ;InformationRleighNCProcessing.617 1,
1617 Mali Service Center,Raleigh,NC 276991617
11.Borehole diameters fo
I 24b.Far Infection Wens: In additi in to sending the form to the address in 24a
12.Well construction methods Pi�vf ��( above,oalso submit one copy of this form within 30 days of completion of well.
(i.e.auger,roteuy,oebk,direct push,eta) cgnstivafioa to the ibIIowffig: ( {
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Rateigh,NC 276994636
13a.Yield(gpm) kV Method of test Cttal•Ch ei-lI MP 24c.For Water Supply&fnfectinl�Wells: In addition to sending the tbrm to
•13b.Disinfection I I`r{{7Q��C the address(es) above, also submit;one copy of this form within 30 days of
Amount: k r completion of well construction to the county health department of the county
where const unted.
Form GW 1 North taamlfna De
partment of>?avvlronmeatai Quality.DIviaionof Water gesoiacas i ' RevlsedL22.2016