GW1--05338_Well Construction - GW1_20240906

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 oliCEL .,- ft Z^.G'f?4 tkatitl )
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap 6cabte)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 70 ft. f� in. .Re ,( Qc-
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: rv?/,9 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) ft. ft. in.
3.Well Use(check well use): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultural 0t nicipal/Public ft. ft. in.
Doeothcrmal(Heating/Cooling Supply) aResidential Watcr Supply(single) ft ft. in,
0IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
',irrigation FROM TO MATERIAL. EMPLACEMENT METHOD&yA�MIO,UNT
Non-Water Supply Well: 0 ft. t7i ft t�L DAB •p �,r r.pc 4 411,401.4
Omonitoring 0Recovery ft. rX ft 1� �JM
injection Well:
ft. ft.
Aquifer Recharge LIGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
EllAquifer Storage and Recovery ()Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test f Stormwater Drainage ft• ft.
DExperimenta Technology 0Subsidence Control ft. ft.
OGeothermal(Closed Loop) DITracer 20.DRILLING LOG(attach additional sheets If neeu ry)
OGeothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grailss ze,eel
0 M3. In ft. (to
4.Date Well(s)Completed: T.c2 3-,Vii Well ID# ,.74' ft' I�,•l R• t©nl 4 60,- ; :)
Sa.Well Location: i"t,:,f,,erstic:• (lcPrOra LIO
ft t ft. W I.+ r Se.1
Liuqe.in oi,',[e., i-100/4S :IOC. 441 ft. X rt. 1^1. rt� - ,,
Facih /Owner Name Facility iD#(if applicable) 7J ft ak5 ft' Ikta ft t '~�I�' `,�r..;
eeJJ "�v
uog3 JUc77,2,`0':ie, W(Lil, /c .47ntill ft. ft. SEP a i ft. ft. 2024
Physical Address.City,and Zip
t r.i•-::Ait.:..
21.REMARKS
Stioifie:3 '':43 U
County Parcel Identification No.(PIN) 'V
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifca' n•
Ate ,ii` g,h" N iri' 3` N5.5 w ,i a73 1.1
6.Is(are)the wells) Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the ael/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©Yes or No with 15A NCAC 02C 0100 or I5A NCAC 01C,.0200 Well Construction Standards and that a
I(this is a repair,fill out known well construction information and explain the nature of the copy girths 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:
S.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also atlac/i additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: .45 5 (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@100'1 construction to the following:
10.Static water level below top of casing: Lie (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: (12 (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
12.Well construction method: �tt_'`± /C.l^ 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.) ,
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) an Method of test: (ri4C'14 tine 24c,For Water Supply&Infection 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 tr
type: ���'�7�1 �U Amount: A'�7 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