GW1--06198_Well Construction - GW1_20241021

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
David Belcher 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
- 4594-A 390 ft. ,':)i R• ‘4,) OM ('V+rah (!t(-e_)
ft. ft. i '
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name •
�� ft. �'�,,� it- Cp.
J is .1)j d t �}t��
4 ON
16.INNER CASING OR TUBING(geothermal closed-loop) C
2.Well Construction Permit#: ()'7q FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State.Variance.etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Q unicipal/Public R. ft in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it. ft in.
Industrial/Commercial OResidential Water Supply(shared) 1S.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply
Well: C) ft ft. i
Monitorin � �(1�( ),�t? q?flt- Cal;pi *l�({Hilt
g ;�Recovery tt ft. C"
Injection Well: ft. ft.
Aquifer Recharge oGroundwater Rernediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test 101Stormwater Drainage . ft. ft.
Experimental Technology 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(rotor,hardness soil/rock type grain size.etc.)
I CO
4.Date Well(s)Completed: I •I •G111 Well ID# /sett• (a(`) n l� Sal-vili Soi l
f'
5a.Well Location: nR• sr) ft• t x`'r?-{r Sc11'01 56 i l
YNt.oel c�' -Innes .c` a In o`t 'JO `t' blue ( 1;re.
Facility/Owner Name Facility ID#(if applicable) 9oft. '70 5 ft. !. _ , _.t i ;r
II (1. V i ) t;� i ft ft !,_ ._
Physical Address,City,and Zip f" ft. ft. 0 C i ft!, I 2 V(4
Y if 21.REMARKS ikoi9
County Parcel Identification No.(PIN) h•f:;-.'7,;
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is{sufficient) ��yy��, (q 22.Certification: e +��/
3(? .2t" 5(A.?}t t N 7Y�l a VI 274, 3i W (i)- - q�/i--�'_ i0• 16 •toff
6.Is(are)the wells)( Permanent or Temporary Signature of Certified Well Contractor Date
By signing tins,fornr,I hereby certi(r that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or EiNo with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdl 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-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: /05 (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd(ferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: ►D (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: Cc (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
t , Pt;� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: f:*1 ,. 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
t'13a.Yield(gpm) ‘ 7 Method of test: (Pr rh47:090 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: 14 a ri%t' ©/tt'D Amount: I(,0: 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