GW1--05015_Well Construction - GW1_20240827

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 3&oIt' 7d1 ft. 5CcPli( elure)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name O ft. u� ft. SO,t>2� in. H.l81?' i(iti ar);zed llf i
16.INNER CASING OR TUBING ig )thermal closed-loops)
2.Well Construction Permit#: 5151+ LA:1 M (1 FROM TO DIAMETER THICKNESS _ MATERIAL
List all applicable'sell construction permits(i.e.UIC.County.State. Variance.etc.) ft. ft. in. -
3.Well Use(check well use): ft. It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural Oyunicipal/Public ft. ' ft. h. I
Geothermal(Heating/Cooling Supply) gResidential Water Supply(single)
ft. ft. in.
Industrial/Commercial 0 Residential Water Supply(shared) — I
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 307 ft.
Monitoring 0Recovery ft. ft. ��"
Injection Well:
Aft.Recharge ft. ft.
q0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery f Sahnity Barrier FROM TO MATES tAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft• ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiFrock tape grain sire,etc.)
0 ft. to ft.
'jandq 561
4.Date Well(s)Completed: i•K(f) 'A Well ID# h ft. ya ft. biaa ` i"F'G
5a.Well Location: ft. ft.
u5ide; ,Cr,nnt
�.t.)in rir Nf�(he5 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
5199 SniLoI�I wn 5 .Dr, n hp:n,xl L a7�53 ft. ft. — r
Physical Address,City,and Zip ft. ft.
AI arrlar)ce 21.REMARKS • . •
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one lat/long is sufficient) ri 22.Certification:
35© 57' man N 79' (ift 37•ya W „....0t,/� - $' i7-ay
6.Is(are)the well(s) ermanent or Temporary Signature of,erti red Well Contractor Date
By signing this form,1 hereby certify that the well(s)wa.s(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or lio with iSA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction in/brnratmn and explain the nature ojthe copy of this record has been provided to the well owner
repair under#21 remarks section or on the back 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 1 GW-1 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: J 45 (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(dw100')
eV construction to the following:
10.Static water level below top of casing: ef� (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: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12.Well construction method P1CJttYf' A;(` 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) .5 Method of test: 614kh 4 'ram 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: H7H 7 D% Amount: Kill CZ completion of well construction tc the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016