GW1-2021-04308_Well Construction - GW1_20210430

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor information:
Nathan Seagle a„ 1 >, 14.AVATERZONES a�"
Fa � �— FROM TO DESCRIPTION
Well Contractor Name ; w
� �S tt. 1 Z ft.
4499-A 2021 j tr. ft.
NC Well Contractor Certification Number ���� .� `15.OUTER CASING for:multi-cased'avells OR LiNER rap Iicable
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 1jilvili`` n Cr,ti+ ft. SO ft. G 1 tn. SDft'Z
�//7 " 16.INNER CASING OR.TURING! eothermat closed-loop)
2.Well Construction Permit#: 3! / / FROM I TO I DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State, Variance,etc.) tt. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. ft. in
Industrial/Commercial Residential Water Supply(shared) tA(GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: C ft. Z6 ft. o -�
Monitoring Recovery ft. ft.
injection Well:
Aquifer Recharge ®Groundwater Remediation 19.SAND/GRAVEL'PACK"ita Iicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:,DRI LLING LOG attach additional sheets if necessa
Geothermal eatin Coolin Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardnes soil mck rain size etc
0 ft. 5 ft.
ft. ft.
4.Date Wells)Completed:3`IZ-Z� Well ID# 5 �o
5a.Well Location: 1-1 o fr' 45—
ft' ,• S
S
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ZZ C 7 FMov _92
Physical Address,City,and Zip
ft. ft.
21 RENIARKS '
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 _IZ_ZI
6.Is(are)the well(s) ermanent or 13Temporary Signature of Certi& ell Co .cior Date
By signing this form.I herebv certifv that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or E3No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this&a repair•fill out known well caavtruc•tion information and explain the nature of the copv of this record has been provided to the well owner.
repair tinder#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: ` Fi' 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple welly list all depths if different(example-3@200'and 1(g1100') construction to the following:
10.Static water level below top of casing: ZS (ft.) Division of Water Resources,Information Processing Unit,
If,vater level is above casing.use^+/ 1617 Mail Service Center,Raleigh,NC 27699-1617 ,
11.Borehole diameter: !o (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: '41/'TJ)-/ 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 Ceefnter,Raleigh,NC 276994636
13a.Yield(gpm) 0-0 Method of test: 5111,1- 24c.For Water Supply&Infection'Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: t){f/T Amount: �G completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcesi Revised 2-22-2016