GW1-2021-00835_Well Construction - GW1_20210402

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4499-A
k. ft
NC Well Contractor Certification Number I5.OUTER CASING for multi-cased wells OR LINER if ap licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. it / io.
Company Name
'16.INNER CASING OR TUBING fitilithe at closed-loop)
2.Well Construction Permit#: 11C FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.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 []Municipal/Public ft. ft in.:
Geothermal(Heating/Cooling Supply) �esidential Water Supply(single) ft ft in..
lndustrial/Commercial Residential Water Supply(shared)
18.GROUT
�J Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. zo ft ,
Monitoring DRecovery ft. ft.
Injection Well:
ft. ft
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. It.
Experimental Technology 0Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,wiVcock type,gmin size,etc)
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
i k. ft
4.Date Well(s)Completed:�J o�S �) Well ID# ft. ft.
to go
5a.Well Location: 6 k. it
� (-14_'A- M90 r„rApB ft. ft
Facility/Owner Name t��`Y�Facility ID#(if applicable) IL
S 54a!lti Fi-eld Tt ft. ft
Physical-Addrlss,City,and Zip ft. ft
1 `-7 21.REMARKS
n, l i.C_ JS � IZI /v e
County
20
Parcel Identification No.(PIN) APR I
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: It
(if well field,one lat/long is sufficient) 22.Certification: informs
p\NR Section
N W
6.Is(are)the well(s) Permanent or OTemporary Signature o Certified We n or Date
� By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or BS o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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 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-I 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: /t-/<- (ft) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 42 (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: G (in.) 24b.For Iniection 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: Air, 'Di/nt I construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) l
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
-7' 4
13a.Yield(gpm) 7�J Method of test: 41)4 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: I G completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources, Revised 2-22-2016