GW1-2021-04341_Well Construction - GW1_20210408

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Nathan Seagle P{,,•+�; 14.NVATER ZONES i
FROM To I DESCRIPTION
Well Contractor Name a p
4499-A 2�21
NC Well Contractor Certification Number
Aqua Drill, Inc. ,�r✓LO�r'II';;, Lli.11 15.OUTER CASING for multi-cased wells OR LINER(Irap licable
FROM TO DIAMETER THICKNESS MATERIAL
Company Name t �':�;..� ��..
ft. k. in. e
/ 16.INNER CASING OR TUBING WeotheeMud closed-loop)
2.Well Construction Permit#: _/$Z FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.U1C,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 E)Municipa(Public ft I ft I in:
Geothermal(Heating/Cooling Supply) E31Zesidential Water Supply(single) ft I ft in.
Industrial/Commercial Residential Water Supply(shared)
iA.GROUT
71 hTi ation FROM I TO MATE1t1A1 EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
Monitoring DRecovery ft. ft.
injection Well:
ft. ft.
_ Aquifer Recharge OGroundvimtcr Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology 13Subsidence Control
I :
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if nkessaryY
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM To DESCRTPTION color,hardness,sot/rock type,grain stzc ete
111) ft. ft.
4.Date Well(s)Completed: Well ID# ft. ft.
ft. k.
5a.Well Location:
ft. z ft.
Facility/Owner Name t� Facility ID#(if applicable) It. ft.
y 2-01 X4 . � T-1) ft. ft.
Physical Address,Ci and Zip
ft. ft.
21.REDIARKS
County 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:
N W
6.Is(are)the well(s) ermanent or Temporary Signature of Certifi ell ctor Dace
By signing this form.I terebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or E]lAlv. with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1(thk is a repair,fill out known well cansn•uc•tion inlormaticm and explain the nature of the eapv of this record has been prm ided 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-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: Z-Zf (ft.) 24a. For All Wells: Submit this form writhin 30 days of completion of well
For multiple wells list all deptlnr ifdiJjerent(example-3L200'and 2@700') construction to the following:
10.Static water level below top of casing: aid (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use'•+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
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: construction to the following:
(i.e.auger,rotary,cable,direct pustt,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) 54b Method of test: '5"' 24c.For Water Suoaly&Iniection Wells: hi addition to sending the form to
the address(es) above, also submitfone copy of this form within 30 days of
13b.Disinfection type: Amount: 16 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
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