GW1-2021-04342_Well Construction - GW1_20210408

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WELL CONSTRUCTION RECORD(GW 1) For Intemal Use Only:
1.Well Contractor Information:
Nathan Seagle 14.IVATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
4499-A Soo tr. . fr.
NC Well Contractor Certification Number
i5.OU'I'GR C.ASWG(for multi-rased svdls)OR LINER Lill licablt)
Aqua Drill, Inc. FROM TO DIAMETER THICKNESS M:TERIAL
Company Name rt L� ft, 1� in. 5
16.INNER CASING Olt 1.1111ING t eathernial clo-sed-Isinni
2.Well Construction Permit#:?A 1 ZerL(ng�, tl oEl FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well eonstrucviun pernmts(i.e.UIC,County,State, Variance,etc•.) ft. ft. in.
3.Well Use(check:well use): ft. R. in.
Water Supply Well: 17.SCREEN
FROM TO DIARETER SLOT SIZE 7'HICKNFSS MATERIAL
C.cultural OMunicipal/Public ft. ft
RGeothermal(HeatingfCooling Supply) OResidential Water Supply(single) g, ft, in.
Industrial/Commercial Residential Water Supply(shared) iN.GROUT
hTiKatiou I FROM I TO I RLITEll E111'LACE..MENTMETHOD&A1IOUi\7
Non-Water Supply Well: ft. zc�lft.
Monitoring Recovery
injection Weil:
PAquifer Recharge oGroundva[cr Rcmediation ft. ft.
19.SAND/GRAI'EL PACK(ifa))licabie)
�AgU1feY$iOCaLe and Recovery Salinity Barrier FROM TO RL%TERIAL EMPLACE'TENT RIETHOD
Aquifer Test DStomiwater Drainage ft. fr.
Experimental Technology Subsidence Control ft. fr.
Geothermal(Closed Loop) O'Tracer 20,DRILLING LOG(altach additional sheets if necessary)
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Geothermal(Heating/Cooling Returil Other(explain under#21 Remarks) FRORM TO DESCRIPTION(color•hardntss,soilhvch,t c.°rain size.etc_)
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4.Date Well(s)Completed:'3-i0-Z I Well ID# 5 Ct. © R.
s)� k,
Sa.Well Location: 3 6 ft. 1,fC ft. ;� � `
t l;�1-.� � :� —C GfC ft. S ft. l5/ _ 1�
Faeiliq,10%nerNameIRPCEIVED-
ft. ft•
_ �Sa;i 511nnr 1C ��
Physical Address,City,and Zip I ft. ft
5c, 21.REMARKS
County _
5b.Latitude and longitude in degrees_minvres(seconcis or decimal decrees: Irlft)rm3tlon Processing nit
(ifwell field one laNlong is sutilcien:) 22.Certification:
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6.Is(are)the well(sl -manent or OTemporary Sim nuz ofCe-' ze on r Date
a-
�,�, ir sig zing this 1ar,�,1 heroky certify Mar the well(s)nvs(were;constructed in accordance7.is this a repair to an existing well: ®Yes or DIN. rrirh l5.i A'CAC 02C.0100 or 15.4 NC.4C 02C'.000 deli Con -::inr 37rm:dards and roar a
iJ'rhi.<is a repair,Jill out knnuv well eonan•uctiorn inrn•nartion and ei7daiu rl;r,u;t„ :, ri; eopv afthic record has peen prnvided to the iveli muter.
repair under=11 remarks section or an the back o%rh&Jonn.
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 ofwells construction details. You may also attach additional pages if necessary.
drilled:
SUBMITTAL I.tINSTRUCTIONS
9.Total well depth below land surface:3YS tft•) 24a. For .AlI Wells: Submit this form Within 30 days of completion of weli
Fin-nruhiple rcelle list all depths i(di jjerent(e.ymnple-3@200'and 3(d 10(P) construction to the f011ottine:
i 0.Static water level below top of casing: 30 (ft.) Division of Water Resources,information Processing Unit,
1i.rarer kz,-el is above casing,axe 1617 Mail Service Center.Raleigh,NC 27699-1617
II.Borehole diameter: (in.) 241b.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
I2.Well construction method: )r 7��1 1 construction to the followine:
(i.e.auger.rotary cable,direct push.etc.) ''
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Division of Water Resources.Underground injection Control Program,
FOR N ATER SUPPLY WELLS OIiTLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) z Method of test:CtrkA :E 7,aG= 24c.For Water SuoDly&Iuiection Wells: hi addition to sending the fonn to
the address(es) above, also submit one coPy of this fonn within 30 daps of
I3b.Disinfection type: amount: completioD of well construction i t the county health depa-iment of the count,
where constructed.
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Form GW-1 ATonh Carolina Department ofEnvironmentat Quality-Division oil Resources'; Revised 2-32-3016
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