GW1--04549_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A ticz ft. Ltog ft. 4 (i. N , t
ft. 1 ft.
NC Well Contractor Certification Number -
15.OUTER CASING(for multi-cased wells OR LINER if a,'liable)
Aqua Drill, Inc. FROM TO DIAMETER
Company Name
0 ft. 6;7 ft. lei r EMBIEM
r� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#• f�/1 '1 i3jn FROM TO DIAMETER'n THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U/C,County.Stale,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft. "' I
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural n unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) otesidcntial Water Supply(single) ft, ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18,GROUT
Irrigation FROM TO MATERIA I. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft• q ft.
Monitoring 0Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soitirock type,grain sirs,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) ft. /1 ft. Cg
v.
4.Date Well(s)Completed: '7- ,.4 Well iD# ft. �(� ft. ''
st
5a.Well Location: ��G ft. F_.7 ft. �,_/►`/
•
Antlfl,q r et4t)VIi 0 ft. t1133r1G ft. ?161.1�e' �1a�3ii"RR'Cat
Facility/Owner Name Facility iD#(if applicable) 1 ft. '77C7 ft. J(; i...'i.5
ft
I4 ,(ji 4.onmi Lotrlf/t Siv-kkiliiiL�.i Alf' aWCi 77 1. ft. .(�I 1 I 2G24
Physical Address,City,and Zip
ft. ft.
T 21.REMARKS 'tJr'
1reA Alit
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one latilong is sufficient) 22.Certifrcatio
35°� 43' at.gi' N S t e' ;.ca'r W 1i B '( '7'C25'024
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form, I hereby certifi'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or No with 15A NCAC 02C 0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,ill out 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:
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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: l' SUBMITTAL INSTRUCTIONS
yt
9.Total well depth below land surface: 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3(000'and 2(a)/00') construction to the following:
10.Static water level below top of casing: (© (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 2 7699-1 6 1 7
11.Borehole diameter: C9 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
^ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: Alf,' 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) 4 Method of test: Ce e 14 'Lille. 24c. For Water Supply& injection Wells: in addition to sending the form to
the address(es) above, also submi: one copy of this form within 30 days of
13b.Disinfection type: 17I('// Amount: i(at7L 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 2-22-201h