GW1-2021-02260_Well Construction - GW1_20210512

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.1VATERZONES
Well Contractor Name FROM TO DESCRIPTIONft. ft.
4499-A
rt. tt.
NC Well Contractor Certification Number 95.OUTER CASING for multi-cased:wells OR LINER(if Applicable)
Aqua Drill, Inc. FROM I TO DIAMETER THICKNESS MATERIAL
15 rt. ft. to... X J
Company Name
/7 16rlNNER-CASING;OR TUB G' eathermal r'losed=loo
2.Well Construction Permit#: 20'L60 to ` FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 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 TMCKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
Industrial/Commercial ®Residential Water Supply(shared) i&GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0, tt
Monitoring DRecovery ft. tt.
Injection Well:
tr. ft.
Aquifer Recharge ®Groundwater Rcmcdiation
19 SANDICRAVEL PACK'tf a "licable
Aquifer Storage and Recovery ®Satinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology ®Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 20 DRILLJNG LOG attach additional sheets if neema
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color hardness, fUr soock rain sirs tc c
ft. _ ft. A
4.Date Well(s)Completed: —Z 2 Well ID# rt. t„ rt. s�
Sa.Well Location: tt. 5.� ft.
�k l�^r.s5-c(7� ft. ft.
Facility/(honer Name Facility m#(if applicable) ft.
ft. ft. Vie(•
6 a/C//T:a �L R/J
Physical Address,City,and Zip
21 REMARKS i
County I Parcel Identification No.(PIN)
Unit
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: „_, �,,„ ••v
(if well field,one lat/long is sufficient) 22.Certification
N W yG t1-7e_ Zi
6.Is(are)the well(s)MIrermartent or 13Temporary Signature ofCertified wel n Date
By signing this farm.I hereby rtifv that the eeq(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or Ea*u— with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
lfthin is a repair,fill out known well c onrtruc•tion infin mation and explain the nature of the copy of this record has been provided to the well owner.
repair tinder#21 remarks section or on the back ofthisform.
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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 7G� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifiliferent(example-3L200'and 2@100') construction to the following;
10.Static water level below top of casing: ,�O (ft.) Division of Water Resources,Information Processing Unit,
1f,vater level is above casing,rise +' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: C. (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: 041 li,P_a& 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) `5 Method of test:rr� �1.trr�_ 24c.For Water Supply&Iniecton 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: I'�;��f Amount: -1 Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department ofEnvironmentat Quality-Division of Water Resources Revised 2-22-2016