GW1--04501_Well Construction - GW1_20240730

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: — I....., � _
I.Well Contractor Information:
David Belcher _
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A tt. %II ft. 140(fill LDS use)
ft. ft.
NC Well Contractor Certification Number _
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 6 ft. I IC► ft. 6,:; in. 5,
DRc2I (v(
16.INNER CASING OR TUBING(geothermal closed-loop)
d
2.Well Construction Permit#: 3L103 FROM TO DIAMETER THICKNESS i MATERIAL
List all applicable well construction permits(i.e.UIC County.State.variance.etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) igResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ®Residential Water Supply(shared)
—
18,GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: © ft. 'X tl` fL .q__` ,� ileac Chipi�„}
tie
Monitoring ®Recovery ft. ft. 7� f�
Injection Well:
Aquifer Recharge ft. ft.
®Groundwater Remediation
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ry fSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) []Other(explain under(121 Remarks) FROM TO DESCRIPTION(color,hardness soiVreck type,grain situ,etc.)
0 ft. 00 ft.
Clcal�
4.Date Well(s)Completed: 1 ra4
17-,gy Well lD# nc 40 ft. `ft. 6
sell �i
Sa.Well Location: ft. ft.
�� �� 4? �_s-f(tC soli
icft. ,( fL
Facility/Owner Name Facility ID#(if applicable) ii0 ft* ft' 1)w11�. ixralAB 6• -�.- 1 L L.:29'4 %�� Aii' ue, i�e;dsi,,u�., 4J An3 ft. ft. �) *IL 3 2024
Physical Address,City,and Zip ft. ft.
21.REMARKS ;'
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: —
(if well field,one lat/long is sufficient) 22.Certifiitt:
les e 17` IS g'' N 7`16' �'�' `7 w ,-�%/ � '7' i 9' ail
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this frmn,I hereby certify that the mil/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or 12 No with 15A NCAC 02C 0/00 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill osi known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks.section or on the hack of this form.
23.Site diagram or additional well details:
You may use the back of this page Io provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 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: gg5 (ft-) 24a. For All Wells: Submit this ror:ar within 30 days of completion of well
For multiple wells list all depths if different(example-3(0,200'and 401001
construction to the following:
10.Static water level below top of casing:, Sri (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: G (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
,,((I above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: A C-1t' fir!' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1O Method of test: Crfi(ntk me 24c. For Water Supply& Injection Wells: In addition to sending the form to
p j «�O��, the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: ITTM / 0 Amount: I(?CY, completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016