GW1-2021-03462_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD(1134-1) i For Internal Use Only:
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1.Well Contractor Information:
Nathan Seagle 14 WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4499-A h• Z ft.
rc. ft.
NC Well Contractor Certification Number 15.OUTER.CASING for multi cased wells OR LINER, a cable
Aqua Drill, Inc. FROM TO DIAMETER THICtINESS MATERIAL
fL ft 0 !� I in. ,p)�Z
Company Name 16 INNER CASINO OR TUBING `eothermaLclosed-loo
2.Well Construction Permit#: t,,P-J✓QkTL 1 0-fb FROM TO DIAMETER THICKNESS 56 TERrAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) & ft. In.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN ".
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OR5sidential Water Supply(single) fL ft. is
Industrial/Commercial Residential Water Supply(shared)
18.GROUT s;
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft. rt j r
Monitoring DRecovery ft. ft.
Injection Well:
ft. iL
Aquifer Recharge 13Groundwater Remediation
19.SAND7GRAVEL PACK:it.a`"livable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. H,
Geothermal(Closed Loop) DTracer 20 DRILLING:LOG`attitch.tidditidniilsheets&necessa ' ;
Geothermal(Heatin COolin Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,harda soiVroek rain etc
ft. ' ft
4.Date Well(s)Completed:5' 5—Z Well EN ft. so 52
ft. �.
5a.Well Location: ft. tLCarwi
ft- eq ft. f
Facility/Owner Name Facility ID#(if applicable) ft. t4
3100 -Peer k= Da n rL
Physical Address,City,and Zip/ 21r REM ft. tL
�7 C 11(/! 1 �'t/► (/� ARKS'
County Parcel Identification No.(PIN) U N " ?
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: nit
(if well field,one lat/long is sufficient) 22.Certification: Prl i' DVVR Secftn
N W -4411— -
G S- 1 E-ZI
6.Is(are)the well(s) rmanent or 13Temporary ignature of Certified c Date
By signing this form,1 hereby erti. that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or o'P O� with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out brown 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �7 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this';
form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ijwater level is above casing,use"+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection 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: construction to the following:
(Le.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) Method of test: 24c.For Water Supply&Iniection 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: Amount: d2 completion of well construction tc 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