GW1-2021-01080_Well Construction - GW1_20210322

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
Wall Contractor Nam. FROM TO I DESCRIPTION
4499-A 0-
IC Well Contractor Ccrtifiwtion Number IS.OUTER CASING for and ad welt OR LINER Of no le
Aqua Drill, Inc. FRO51 Td DIAMEm I TmCRNF85 MATERIAL
ft. R 1 is
Company Namc
IQ INNER CASING OR TUBIttG thttmal dosed-Ioo
2.Well Construction Permit#: 1376 FROM I TO DIAMEBR TmCIQ S I MATERIAL
l.Grt nl/appfimhe veil cmmtvctinn pernarr/Ce.U1C.County.Stare.Parlance,etc.) R R in.
3.Well Use(check well use): D. R in.
Water Supply Well: 17.SCREEN
FROM I TO I DIAYIETEt I SLOTSIZE I TRICKNUS I MATERIAL
Agneullural []Municipal/Public 0 ft. R la
Geothermal(Hcating/Cooling Supply) 5esidendal Water Supply(single) D. ft.
Industriat/Commerc(al Residential Water Supply(shared) 18.GROUT Irrigation mom TO I bUTEMAL IEMPLACEMFMMEIHOD6AMOONI'
Non-Water Supply Well O fL 2G fL L
Monitoring QRecovery R. R
Injection Well: R 0,
Aquifer Recharge DGroundwater Remediation 19 SANDlGRAVEL PACK fe le
Aquifer Storage and Recovery OSalinity Border o huTf7t1AL EMPLACEIVIE ThIErHOD
Aquifer Test DStormwater Drainage fL
Experimental Technology 7ir
Subsidence Control ft
Geolhermal(Closed Loop) DTricer 20.DRILLING LOG attach additional sheets Kneeesaa
Geothermal(Heating/Coolin Return) M01her(ezlain under#21 Remarks) EOM To orsa[�rwN eotor.6..ann,.roarmeh ,hem
v R 5 R I c
4.Date Well(s)Completed: 2--11-21 Well ID# 3 ft 30 (L
5a.Well Location: O R 3f- ft S l C
� R 260 R .
Facility/Owner Name Facility ION(if applicable) fL D.
R IL
Physical Address.City,and Zip R R
s
G`I/V Sea•,)1 21.REMARKS
Coumy Parcel Identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field.one Intllong is sufficient) 22.Certification:
N W �//
6.Is(are)the weli(s)0P�manent or Temporary Sipmt>�fCerti cd�y onlnGor Doe
#v signing rho f°mt.1 hereby rem drat the ndl(s)a.(were)constructed in accordance
7.Is this a repair to an existing well: QYes or QN-o with 15.4 NCAC 02C.0100 or I5A NCAC 02C A200 Wall Cmutmcrion Smwlotrlr and/,at n
lfilus is a mMig fill on,known wit wrutractionJ.fommrion awl explain lite nature of the copy°f1hu recoN has been provded 1.th,veil rather.
mpair makr 421 remarks section or on the back oflha form.
23.Site diagram or additional well derails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some 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. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 21 00 24a. For All Wells: Submit this form within 30 days of completion of welt
him ntulupla yells list all depths f differaw(erample-3 a@200'mw120d100)
construction to the following:
10.Static water level below top of casing: .30 (ft) Division of Water Resources,information Processing Unit,
gums(eve/is mbar,casing.rise'•-' 1617 Mail Service Centel,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Inieetion Wells: In addition to sending the forth to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Alen D711 t I construction to the following:
(i.e.auger,rotary,cable,dime[push,eta)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 7- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) .s Method of test Gf/0,d //r+rC 24c For Water Supply&Inieetion Wells: In addition to sending the to=to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 6 Amount: 12 o�z completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016