GW1-2021-05440_Well Construction - GW1_20210503

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.WATER ZONES
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Well Contractor Name FROM TO DESCRIPTION
4499-A 3.202� vo ft. Zf ft.
MAX X tt. ft.
NC Well Contractor Certification Number UNIt I&OUTER CASING for milli-cased wells OR LINER if a Itcable
Aqua Drill, Inc. ►;,Scl►:.a�lOn�ratc�s,rt�7
FROM TO DIAMETER THICKNESS MATERIAL
eiE^1;OI1 � ft. S tt. / I Lj
Company Name ^� l� 16.INNER CASING OR TUBING deothermilAosed-loo
2.Well Construction Permit M. W O��® ` ^ ©�1 FROM TO DIAMETER THI
CKNESS 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
NAgricultural 0Municipal/Public ft. ft. in
Geothermal(Heating/Cooling Supply) r ential Water Supply(single) ft ft.
Industrial/Commercial 13Residential Water Supply(shared) TH.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: (5 ft. 20 ft.
D
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
:-)Aquifer Recharge E)Groundwatcr Remcdiation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barer FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stortnwater Drainage
Experimental Technology 13 Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach'addllldual Amu If necessary
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness sorltrock type,grain size etc
R. I ft.
4.Date Well(s)Completed: "2 Z Z I Well ID#
Sa.Well Location:
V ft. 4 ft.
Facility/Owner Na a Facility ID#(if applicable) ft. ft.
//G rt. D.
Physical Addressff ny,and Zip
ft. ft.
J_C_:e,n rV/P.v�t JO I Coo%3 7 3 G 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
N W
6.Is are the wells Permanent or Temporary Sigiiature of Wel cto Date
By signing this form,I hereby Iii,that tire wells)it-as(were)constructed in accordance
7.Is this a repair to an existing well: [3 Yes or E3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ff this is a repair,fill out known well c•onsn•uction in1brnmtion and explain the nature of the cape of this record has been provided to the%ell mvrter.
repair under#21 remarks section or on the back ofihisJorm.
23.Site diagram or additional well details:
R.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: Z (ft.) 24a. For All Wells: Submit this form xithin 30 days of completion of well
For multiple wells list all depths ifdi ferent(example-30200'and 2(a) 001 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
Ifsvater level is above casing.uses"+^ 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: fo (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:'/ i��rf 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
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13a.Yield(gpm) I6c Method of test: 24c.For Water Suably&Injection Wells: Ili 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�/C1 completion of well construction to the county health department of the county
where constructed. R
Form GW-1 North Carolina Department of Environmental Qualiry-Division of Water Resources Revised 2-22-2016
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