GW1-2021-04234_Well Construction - GW1_20210419

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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 'I'O DESCRIPTION
4499-A
NC Well Contractor Certification Number 15.OUTER CASING(for:multi-cased.wells'OR LINER"ifa 'licable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
rt. ft. 114' in. .
Company Name q 16.FROM
INNER.G TO DIAMETER I THICKNESS MATERIAL SING OR TUB _
2.Well Construction Permit#: A� 1 � �`�
List all applicable well construction permits r.e.UIC,County,State, Variance,etc.) fr. ft. In.
3.Well Use(check well use): ft' ft. in.
17
Water Supply Well: SCREEN .
FROM TO DIA11rETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 5R.6idential Water Supply(single) ft. ft. in.
Industrial/Commercial ®Residential Water Supply(shared) 113 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: t'� ft. `2-6 ft•
Monitoring Recovery ft. ft.
injection Well: fr fr
Aquifer.Recharge [3Groundwatcr Rcmc Nation
19.SAND/C RAVEL PACK;(i a licable
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT"METHOD
Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRiLLING LOG attach additionatsheets if necesm
Geothermal(Heating/CoolingReturn) Other(explain under 421 Remarks FROM To DESCRIPTION color,hardness,soit/rock rain sera eta
rt. ` fr.
4.Date Well(s)Completed: 2-2 7- -# Well ID# ft. 7 • ft.
�5ra.Well Location:
ft-
Facility/Owner~Name Facility ID#(if applicable)
4J L .r
Physical Address,City,and Zip
21.REDfARKSFt
County 1 Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification ,r''Jll,�e Y`a C�C•L.fl�
N W - :e&&_ 2•Z3- Zi
Signature Date
6.Is(are)the well(s) anent or 01remporary
By signing this form.I Irene certi� that the uzll(s)was(were)constructed in accordance
7'Is this a repair to an existing well: ®Yes or with I SA NCAC 02C.010 or I5A NCAC 02C.0100 Well Construction Standards and that a
copy n this record has been provided to the well owner. -
!'thzr U a repair,fill out known well c•nasnuction information and explain the nature of the j p - _
repair under#11 remarks section or on the back ofthisforni.
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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: Z ?L S (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fit di,[je-ent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: C.o (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use
f"-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (G (in.) 24b.For Infection 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: "/r �V.`, 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) 7 Method of test: 1� 14c.For Water Supply&Injection 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: &&Z completion of well construction to the county health department of the county
where constructed. i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources =Y Revised 2-22-2016
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