GW1-2021-00836_Well Construction - GW1_20210402

Prin Form.
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle la.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
4499-A I G -ft• ft.
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a liable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. 60 ft-
t l bil in. 5•,
Company Name 16.INNER CASING OR TUBING eothermal'closed-loo
2.Well Construction Permit#: ZD21 t7 1 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. fL In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
J IndustriaUCommercial [DResidential Water Supply(shared) 18.GROUT
Il'rt atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0
ft. fL
Monitoring DRecovery ft. ft.
Injection Well:
ft. fL
Aquifer Recharge Groundwater Remediation 19:'SAND/GRAVEL PACK(if.a liable
Aquifer Storage and Recovery E)Salihity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control fL fL
_ Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
_ Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO ft. fL DESCRIPTION(color,hardness,wilfrock type,grain size,etc.)
4.Date Well(s)Completed: 3-2%-2 Well ID# ft. ft.
1/1 4 ey Sec
5a.Well Location: L
ft. rL
ft. fL
Facility/Owner N net }.� , l Facility ID#(if applicable)
ft. ft.
^t�1 -t—1 �!1 71 G n M+ ft ft
Physical Address,City,and Zip
ft. %
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
rocessing Unit
�f well field,one laUlon +s sufficient cPntioll
( g ) 22.Certification: D��R '
N W �
3~Z� )
6.Is(are)the well(s) fmanent or OTemporary Signature of Certified + on or Date
By signing this, I here y certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or �Aio' with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If 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 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: J (ft-) 24a. For All 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: (i (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: (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: I M o+I I 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
13a.Yield(gpm) Method of test: S ln_� 24c.For Water Supply&Iniection Wells: In addition to sending the form to
j the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 1 t It Amount: Ile 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