GW1--05023_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD GW_1
For Internal Use Only: --
I.Well Contractor Information:
David Belcher
Well Contractor Name 14•.WATER ZONES
FROM TO DESCRIPTION
4594-A q$OfL 44(2 ft. 4&QM t rf'4CA-tlfa 7
NC Well Contractor Certification Number ft I R.
Aqua Drill, Inc. 15.OUTER CASING(for multi-cased wells)OR LINER if ,, 'cable
FROM I TO DIAMETER THICKNESS
MATERIAL
Company Name 0 ft. t 1a ft _I
r . .. C in, '�J e ill 6r�1�Qn;Led t
2.Well Construction Permit# 5a W �. �u�� 16.INNER CASING OR TUBING' Ieothermal closed-loop)
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) FROM TO DIAMETER THICKNESS MATERIAL
ft. n is
3.Well Use(check well use): ft.
ft. in.
Water Supply Well: 17.SCREEN
Agricultural Oy unicipal/Public FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft' ft. in.
Geothermal(Heating
/Cooling Supply)pp y) gResidential Water Supply(single) —
Industrial/Commercial ft- ft. hi.
Residential Water Supply(shared)
Irrigation 18.GROUT —
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
e ft. (2a fL
Monitoring Recovery 1',1()r Qi)ur(hp +}� ra.�
Injection Well: ft ft. r'
Aquifer Recharge illGrotmdwater Remediation ft. ft.
Aquifer Storage and RecoverySalinity Barrier 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage ft. ft.
Experimental Technology D Subsidence Control
ft. ft.
Geothermal(Closed Loop) 0Tracer
20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock
ft. se) 4'PG grain sbc,etc.)
ft.
4.Date Well(s)Completed: 3q e2al �': 'e r
WellID# 2 ft. ft,
t`Jil` _
5a.Well Location: It/ 5 !)!f ft. ft. tie 6w1t
Littr 14ones H• ft.
e
Facility/Owner Name Facility ID#(if applicable) ft. ft. -
�.0+16) 53'1 Wen is Mr (1- hc��►) � ft. ft.
Physical Address,City,and Zip ?4 A I I G 9 i ')f 7I
ft. ft.
Al t1iv wi c . 21.REMARKS
County Parcel Identification No.(PIN) T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
gg � rJ�I.(p; 37,q4 22 Certification
J
�E ir N ��� I�. W
l � 'is,e77
6.Is(are)the well(s) ermanent or Temporary Signature of Certified Well Contractor
Date
gning this form,I hereby
7.Is this a repair to an existing well: ®Yes or No wiht ISA NCAC 02C.0100 orISAt NCAC ify t02C.0200 W the well(s)ell Consetruction Standards and accordance ta
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#21 remarks section or on the back 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 I 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: S(;5 (ft.)
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@100') ons c
construction to the following:
10.Static water level below top of casing: c20 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use'•+'•
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: G (in.)
24b. For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Air' above, also submit one copy of this form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary.cable,direct push,etc.) Q�J
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) U Method of test: t-141ifl 4 MAI, 24c.For Water Supply&Infection Wells: In addition to sending the form to
iI n r the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: n TN 7Q ie Amount: II0.Q1. 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 W,,P,P,,,.,,,00e