GW1--05931_Well Construction - GW1_20241009

I
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information: I I f
David Belcher
14.WATER ZONES •
Well Contractor Name FROM TO DESCRIPTION
4594-A - 9(IZd. o e% t li COP (Virach.t.i e)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO I+ DIAMETER THICKNESS MATERIAL
Company Name 0 ft. I `70 ft. I G ''p°in.
16.INNER CASING ORTUBINGI(geothermaldosed.00p)
2.Well Construction Permit#: I�R(,+. L.61( /401i4T6o 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): , ft. ft. in. -
Water Supply Well: 17:SCREEN
Agricultural FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0/unicipal/Public ft ft.
in.
Geothermal(Heating/Cooling Supply) g'Residcntial Water Supply(single)
ft. rt. in.
Industrial/CommercialResidential Water Supply(shared)
18.GROUT - -
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
ft. 475 fL ' estop Pour Chirps el•-1-Ir4.l(MS'
Monitoring �Rccovcry ft. ft
Injection Well:
ft. f.'Aquifer Recharge �G roundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(if applicable). •
ty FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test DStormwater Drainage ft. ft.
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary).
Geothermal(Heating/Cooling Return) }Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sod/rock t pe,grain sac ern)
0 ft. 090 ft. Ow
4.Date Well(s)Completed: IC)q,=Rai Well ID# ft. GO ft. 1.1 /1 �� p Sell
�^ y `
5a.Well Location: ,a o ft. 170 ft. �LI// Gaf,,,k ' (� • :-, ``,,''_,. . ,+.T:.,.
Cast hDn Mto1 e [Ira►l beno po ft. cA, ft. l cim1I rT to '
Facilitwner Name Facility ID#(if applicable) ft. ft. �) ` un L I��
( 2) 1) �r� ( ttAMf1IR pp S:�IQQSr1 i 990�7 ft. ft. r.•Np,< �-+ ��
Physical Address.laity.and Zip ft. ft. V':dc )
irry 61,9.4,00'1rog' v 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.Certifies' II:
gi/Z______ i 1
go
6.Is(are)the wells) iPermanent or OTemporary Signature of Certified Well Contractor , Date .
By signing this form,I hereby certi�5'that the null(s)was(were)constructed in accordance 7.Is this a repair to an existing well: ®Yes or No wit/r!SA NCAC 02C.0100 or/SA NCAC 02C.0200 We!!Catuslrrcrion Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the cope 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:
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: 1SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,7 I (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it-different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 50 I (ft.) Division of Water Resources Information Processin Uni
Ifunter level is above casing,use"+" g t,
1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.)
24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: rikfrkray Ali` 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) q Method of test: ( 4 h+lime, 24c.For Water Supply&Injection Wells:'In addition to sending the form to
yy / the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 14�y® aG€ Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016