GW1--04973_Well Construction - GW1_20240816

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: t
1.Well Contractor Information:
David Belcher 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A 5 .Oft. 59'a ft. 10 CaPi C w4u.�1
ft. ft. 1
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
0 ft. ►0©ft. Co. 05 in. s VP1 e2t PVC -ICompany Name yy
16.INNER CASING OR TUBING ll;eothermal closed-loop)
2.Well Construction Permit#:6041M-42paq FROM TO DIAMETER THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC County.State,Variance,etc.) ft. fL in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q nicipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in
Industrial/Commercial E3Residential Water Supply(shared) 18.GROUT 1
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 9"' ft. 111, ilionr QG, r ttps +Pyd rate
Monitoring Recovery ft. a ft- Gf ►R
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation _
Salini Barrier 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery
® ry FROM TO MATERIAL EMPLACEMENT METHOD _
Aquifer Test fStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) QTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiVrock type,grain size,etc.)
�f /0 ft. Soft. owe._
4.Date Well(s)Completed: i°j;�•,,,fu Well ID# A.J ft. ft. `) e ;
5a.Well Location: GO ft, 95 ft, Li 14
Alton ?smell 95 ft' lOD ft. ' id, _
Facility/Owner Name Facility IDS(if applicable) I�© ft, 605 ft• •ci h1__� `
1QCTJ r.)t - i..,i.�
3311 1 n4 c' t Lyle i Y(144l)411)0, (, ,AY .47055 ft. ft
ft. ft. {{^�f(� 1 ;• Z024
Physical Address,City,and Zip
%Ail 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.Certifie n
3c,` '7' 19.7' N IV 35' i5•ut' w ."8
$ I3-
6.Is(are)the well(s) Permanent or Temporary Signature o 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: ®Yes or No with 1SA NCAC 02C.0100 or 15A I/CAC 02C.0200 Well Construction Standards and that a
grills 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#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 to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells contraction details. You may also attach additional pages if necessary.
drilled:
,^�LL SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 645 (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 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: (O (ft.) Division of Water Resources,Information Processing Unit,
If neater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: Co (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
a_ Qt }f6�,^ above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: r 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) 10 Method of test: Cakh 4 i itne, 24c.For Water Supply&Iniection 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: H Vii(De in Amount: i(DOL 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