GW1--05932_Well Construction - GW1_20241009

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 0 ft, xp ft 4 OQI'd� 't�G�'4�ce)
ft. ft.
NC Well Contractor Certification Number
15.OUTER CASING(for multi-eased wells)OR LINER(if au licable).
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS 4I MATERIAL
Company Name .A ft 70 tL 6.95 in. o I1 I '{e
//�� 16.INNER CASING OR TUBING(geothermal closed-loop) i�tr
2.Well Construction Permit#:'I`1IaJQ.,9 011 qW/! FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(le.UIC,County.State.Variance.etc.) ft. ft in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural unicipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) VI Residential Water Supply(single) ft ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT - -
Irrigation •
- FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft dt. ft. t ei p,' ur Ch;��
Monitoring DRecovery ft. ft n fGJ
Injection Well:
ft. ft.
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery Salini Barrier 19.SAND/GRAVEL PACK(If applicable) - " -
ty FROM -TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft.
Experimental Technology (Subsidence Control ft. ft.
Geothermal(Closed Loop) ljTracer :20.DRILLING LOG(attach,additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) soitrroek type.grain etc)
➢ © it. ft. Ciet
4.Date Well(s)Completed: 1 i°q•p2t/p Well ID# R• O7 FC 3 ft r A
5a.Well Location: 'fto 70 0li K� �eCt,I
, ^ -
p1G lf9!1 A EDM ' , ft. 325 ft' %' e• /+ _ '"`�.•
Faacil Owner Name •�1 1 Facility ID#(if applicable) ft it •
OCT
r W 20
L4
tfil D KirL pjQLs)tV1Qf1 NJ.) 3':inimJ p�'7d7, ft. ft _
Physical Addres ity,and Zip ft ft
SLIT m/ 59,/ -o n-L'I -0' � 2I.REMARKSt ' -.. . ". _ `'
County Cf Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: _
3_6.° ifi' GY.3" N el eA R`.; ' 077.8 n w �
_00,-
6.Is(are)the well(s)iermanent or oTemporary Signature of Cc ified Well Co r "Date
By signing this form,1 hereby cert 'that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: nYes or EiNo with 15A NCAC 02C.0100 or iSA 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 tinder#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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
r/ G SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5l2J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diffOrent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: SO (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: C.1 -(in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
((r above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: wintry ih r" 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
1 ,
13a.Yield(gpm) ( Method of test: Cepkhr1 gat-1!Ad 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: 141i-1 700fe) Amount: liC.0.0Z completion of well construction to the county health department of the county
where constructed. I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016