GW1--05077_Well Construction - GW1_20240827

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: I— ---
1.Well Contractor Information:
David Belcher
14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4594-A (� ft. rt.
f ax' Pi 10 ft?"A ( 1(zt hi;e)
NC Well Contractor Certification Number ft. ft.
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
Aqua Drill, Inc. FROM f TO DIAMETER 1 THICKNESS MATERIAL
Company Name 0 f t. Cu• ft. I m.
16.INNER CASING OR TUBING Geothermal closed-loop)
2.Well Construction Permit#: L ,A-,29 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. U/C County.State. Variance.etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: i 17.SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
® unicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft, ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: D ft. 2,2 it,Monitoring QRecovery r�1�7'thtk Poo- Ch,pS Utirak
ft. R.
injection Well:
Aquifer Recharge ft. ft.
g Groundwater Remediation _
Aquifer Storage and Recove 19.SAND/GRAVEL PACK(if applicable)
ty fSalinity Barrier FROM To MATERIAI. EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(I leating/Cooling Return) nOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiUmck type,grain size,etc.)
OV fft. at l ft. \ k
4.Date Well(s)Completed: g' j q.rx'c! Well 1D# ft. ft.
' L Sex:k cr.:j ,.
5a.Well Location: 11Q ft. CSC? R. �.tLLS@n' SO4 _
CiJr+iS + C fh;a C'-'j ;n `1}r� G:4) ft. 655 ft. &Q(1_.Gft. tfe A i__i.
Facility/Owner Name Facility ID#(if applicable)
eQQcn S c 1 4,1'I CilLa h 'Rd, 'i/Ifion, .vc ' l ft. R. — I (, ? 7 2624
Physical Address,City,an8 Zip ft. ft. b
DQu; CW1 02rtK,gtiCerL^C300SA 21.REMARKS
County Parcel Identification No.(PIN)
— 'R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient)
35 9pp �r y�,��.� +'yL.. 22.Certification: �s
6 7I' 3. tr N Oci I1 6t:r,l le W 1?li/ lJ 8
6.Is(are)the well(s)riPermanent or Temporary Signature of Certified Well Contractor Date � �
B)'signing th form,i hereby certi(v that the wets)was(ivere)constructed in accordance
7.Is this a repair to an existing well: EiYes or NO with iSA NCAC 02C.0100 or 1SA 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#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
R.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:
�r� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.)
For multiple wells list all depths ifdijjerent(example-3@200'and 2@100') ons c For All Wells: Submit this form within 30 days of completion of well
construction to the following:
10.Static water level below top of casing: 10 (ft.)
If water level is above casing,use..+' Division of Water Resources,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method: 1 ;f` above, also submit one copy of the 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
j.13a.Yield(gpm) 10 Method of test: Crt+cn 7r'M!e 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: Tu/(��+ '
10 Amount: jCoCZ completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Departtnent of Environmental Quality-Dis rsion of Water Resources
Revised 2-?0-2016