GW1--04557_Well Construction - GW1_20240731

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
I.Well Contractor Information:
David Belcher _
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A a'9 Dtt. i ft. i 0,,4 (rI•a iace)
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 ft. ft. in.
16.INNER CASING OR TUBIN (g) ermal -loop)
2.Well Construction Permit#: , Wt c 1(f)C -06g FROM TO DL IETER HICKNESS 1 MAtERIAL
List all applicable well construction permits(i.e. U4C.County.State. Variance,etc.) ft. ft. in�. 1
3.Well Use(check well use): ft. 7n,
Water Supply Well: 17.SCREEN /
Agricultural FROM TO . TER SLOT SIZE THICKNESS MATERIAL
g unicipal/Public ft. ft. n.
fGcothcmlal(Heating/Cooling Supply) 'Residential Water Supply(single)
ft. ft. in.
9 Industrial/Commercial DResidential Water Supply(shared)
18.GROUT '
Irrigation FROM O M TERIM, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
Monitoring 0Recovery f Injection Well:
aA uifer Rechargeft. ft.
qGroundwater Remediation
Aquifer Storage and Recove 19. ND VEL PACK(if applicable)
ry 01Salinity Barrier FROM ) MATERI Si. EMPLACEMENT:METHOD
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
®Geothermal(Heating/Cooling Return) 0Other(explain under#21 Remarks) FROM To DF.SCRIFTION(color,hardness soil/rock type,grain nice.etc.)
ft.
ft.
!!�li105 / a. l e
4.Date Well(s)Completed: 17" 17.AWell iD# ft. ft.
Sa.Well Location: R. ft.
ft. ft. • *l-
atubl?+1� f_ChcA5 .
r!°-
Facility/Owner Name Facility(Da(if applicable) ft• ft.
;AO �kQ Dr, Re:d4611E, apt: a7320 ft. ft
J JL 3 2024
Physical Address.City,and Zip ft. ft.
RROCY12.yhiCtA 49i5ertIV34Oki 21.REMARKS
County Parcel Identification No.(PIN) _
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification:
3&C col/ Li,3t' N 79 3,2' 53-9ta `` /� _
6.Is(are)the well(s)illigiPermanent or Temporary Signature of Certified Well Contractor Date �� y
Br signing this ftrnr, l hereby certifi that the aeil(s)ryas(were)constructed in accordance
7.Is this a repair to an existing well: Yes or QNo rrirh I5A NCAC 02C 0100 or/SA NCAC 02C 0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner
repair under 42/remarks section or on the hack alibis form.
23.Site diagram or additional well details:
You may use the back of this page to 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: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if-different(example-3@)200•and 2@l00')
"� construction to the following:
/
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water(evel 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
12.Well construction method ��`tQ1 L� p�(' above, also submit one copy of this form 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I Method of test: h
C' 4C 4.rfnt 24c.For Water Supply& Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: )I TW 7O+ /o Amount: haOZ 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 Res ised 2-22-201h