GW1-2021-01069_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
W01 C.atrao.,Name FROM TO DESCRIPTION
4499-A 3crf`' to R,
ft. ft.
NC\1'dI C'on[mctor Ccrtilication\umber 15.OUTER CASING far mullFeased wells OR LINER Firms, 11eable
Aqua Drill, Inc. FROM TO DIAn ETER IHR'kxLM MATERIAL
Compan m y Nae
t) ft. Tf ft. 6 Ile, in.
16.INNER CASING OR TUBING Thermal closed-1
2.Well Construction Permit#: �uLl1/� JLJ/� '��/ FROM TO DLUIETER THICKNESS MATERIAL
Latall upplirmhleoell ourobv,,... ermiLsli.e. GIG'.Cimnm,Sbnr. r'wdannt err./ ft. R. In.
3.Well Use(check well use): D. ft.
17.SCREEN
W 91er Supply Well:
FROM TO DIAMETER SIOTSIZE THICKNESS MATERIAL
Agricultural �mmucipal Public ft. ft. in.
NGetnhertal(Heating Cooling Supply) esidential Water Supply(single, ft ft In,
IndustriaVConunercial OResidential Water Supply(shared) 19 GROUT
in-neation FNOM TO MATERIAL EMPLACEMENT NIETHOD&.AMOUNT
Non-Water Supply Well:
Monitoring DRecoxery
l'aGeothermal
(Closed Lop) Tracer 20.DRDection Well:quifer'Recharge �Gmundwmtcr Rcmcdiation19.SAND/GRAVEL PACK i(a inhle
quifer Storage and Rec(ls'ery �Salunty Barrier FRAM TO MATERIAL EMPL\CEMENT METHOD
quifer lest �Stomiater Drainage D. ft.xperimental Technology Subsidence Control
.LING LOGaltseh addiHoaal sheets it necessary)
umhermil(IleaGn /Coolie Rehm) Other(ex lain under ft21 Remarks) FROM TO DESCRIPTION color,haNnox wIV.k inA,a,em.
ft. ! ❑.
4.Dale Well(s)Completed: Z-/L-Z/ Well IN S' D, 6t% n, �.
5a.Well Location:
A. n. �.
Xit, rL cI� n.
Facility lharer Name 1-.'flay lD-(it applicable)
fu ft.
Physkal AJJress.City,anJ Zip n. H.
21.REMARKS
County / Purcrl ldeffloicaliun N11.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
it well field,one,.thong is suflicient) 22.Certification: y
6,IS(are)the well(,)"Permanent or Temporary Signature ofcenitied WqLtV&uact Date
8 vrg t rR d s loan.1 her robe rth"thm t/re>,ell(s) as (werer rormrueled,n arcurdnnre
I` 7 Is this a repair to an existing well: Yes or ❑NO Uh I f J NC AC WC 0100 or /5A NC iC 02(-0200 Well Con,....ion SMnalvd,a,rd that a
$Jn L .,,I h,Jill ut kn nnrel/ n,vruaaon hifi,r urea-,and expluln the mnw'e ,/the ...P,• /tl. rerardlra hen Pro,ld"I the xwll..toner
repair undo #21 rewark...:[,on or on the bark of th,form.
33.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal W ells 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 ofwells construction details. You may also attach additional pages ifnecessary.
drilled. SUBMITTAL INSTRUCTIONS
9.1otal well depth below land surface: SOs" (fh) 249. For All Wells: Submit this form within 30 days of completion of well
F,,mulrip[e,velLy hmall d,,h ddilfn'enr(emmple-3C,200'und 21n,100) construction to the following:
10.Static water level below top of casing: `/O (ft.) Division of Water Resources,Information Processing Unit,
!/„rarer le.,el is above rasing.vse 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b. For Infection Wells: In addition to sending the form to die address in 24a
12.
above, also submit one copy of this form within 30 days of completion of well
n, construction method: (�C , l�r (\
(i.ee..auger,rotary,u.ble,direct push etc, construction to the following:
Division ofWater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 769 9-1 636
13a.Yield(gpm) / Method of test: Z j" sue 24c. For Water Suppl% & Iujection 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:ZZ� Amount: Z completion of well "instruction to the county health department of the county
where constructed.
Form G W-I North Camlina Depannient of Environmental Quality-Division of w'mer Resources Revised 2-22-201 h